Last Updated on: 9/3/2021
Fee Schedule Instructions Historical Behavioral Health Fee Schedules Fee Schedule Formats Format of CSV Fee Schedules Special Indicators on Fee Schedules Table Listing
Fee Schedule Instructions Welcome to the Connecticut Medical Assistance Program enhanced fee schedule page. The fee schedules have been enhanced to provide different formats that can be easily viewed, downloaded and manipulated, and that have historical rate data. To reference provider bulletins with important fee schedule information, navigate to the Information page of this Web site by selecting Information > Publications and use the Publication Search feature to find provider bulletins for your provider type.
Limited policy restriction information is only provided on the fee schedule. For a comprehensive set of policy information, please refer to Chapter 7 of the Provider Manual. To reference provider manuals, navigate to the Information page of this Web site by clicking on Information > Publications > Provider Manuals to find the provider manual for your provider type and click the “View Chapter 7” button.
For enhanced pediatric and obstetrical services rate information, please review further down in the document the section titled Available Fee Schedules and the information provided under the “additional information column” for both the “Physician Office and Outpt Services” fee schedule.
Historical Behavioral Health Fee Schedules This link contains Behavioral Health Partnership & Psychologist fee schedules produced prior to April 1, 2012.
Fee Schedule Formats The most current fee schedules are now available in one of two formats as follows: o PDF –Portable Document Format - Fee schedules in this format (easily viewed and printed with free Adobe Acrobat Reader) contain footnoted information pertaining to some specific policies related to the procedure codes. This is a picture that cannot be sorted or modified in any way. This document can be saved to your PC. It is
1 important to note that this version is updated annually or when there are significant numbers of updates. o CSV – Comma Separated Values - A CSV file type can be opened in Microsoft Excel or other spreadsheet programs. This file type is available to providers in the event that providers would like to use the fee schedule data for any necessary calculations. This fee schedule format can be manipulated as any other Excel document, with available spreadsheet features such as sorting, filtering, and adding columns. Please note the following tips when using the CSV format. o To open a fee schedule in this format, simply click on the CSV link next to the appropriate fee schedule. On the Pop Up box that appears, press the Save button and Save in the folder of your choice and with the name of your choice. Go to folder where the file was saved and open the file. After it is open, save the file in the desired spreadsheet program by selecting the file type, such as Microsoft Excel. o Once the file is opened, providers will have to expand the column size of each of the columns. Providers may then perform any functions available in the selected spreadsheet program, such as sort, filter, print, and add columns. o If the provider is interested only in current rates and not historical rate data, use the filter function of the selected spreadsheet program to filter by the effective date. If the provider is interested in viewing current and historical rate information, do not apply a filter. o If the fee schedule is to be printed, it may be wise to choose landscape and add page numbers using the page number feature of the selected spreadsheet program. o If the CSV link doesn’t work for you, you may need to point to the link, right click and select Open to access the CSV format and/or on the pop-up blocker setting page there is a drop down with the Blocking level. If you have this set to "High" Then you need to override the popup blocker settings. You can investigate your settings in either of these ways:
▪ Tools | Pop-up blocker | Pop-up Blocker Settings | set the Blocking level to Medium ▪ Tools | Internet Options | Privacy tab | Click the Settings button in the pop- up blocker area | set the Blocking level to Medium
Format of CSV Fee Schedules Each fee schedule contains the following data: • Heading – Indicates the name of the fee schedule. • Procedure Code – Indicates each procedure code that can be billed for that fee schedule. • Proc description – Includes a description of each procedure code.
2 • Mod1 – Includes any modifiers that can be billed with the procedure code. Modifiers will not be applicable to all fee schedules. • Mod1 Desc – Includes a description for the listed modifier. Beginning mid-May 2009, this field will be excluded on MEDS Fee Schedules. • Rate Type – The rate type is used to further define the type of rate for the provider fee schedule. Some fee schedules may only have one rate type, whereas others may have multiple rate types. The rate type gives DSS the ability to reimburse procedure codes at a different rate amount based on criteria such as client age or gender. • Max Fee – Indicates the maximum fee payable for that procedure code. • Effective Date – Indicates the effective date for that rate type and max fee amount. The fee schedule may contain multiple rate types, max fee amounts, and effective dates so that providers have historical rate data. • End Date – Indicates the end date for that rate type and max fee amount. • PA – Indicates whether or not prior authorization (PA) is required. If the column contains a value of Y then PA is ALWAYS required for a procedure code. If the PA indicator lists an “*” asterisk; that implies the PA applies to specific billing rule situations, not all. Ensure that you refer to Chapter 7 of the Provider Manual for situational PA requirements as this field shows codes that ALWAYS require PA. To reference provider manuals, navigate to the Information page of this Web site by clicking on Information > Publications > Provider Manuals to find the provider manual for your provider type and click the “View Chapter 7” button. • QTY – Applies only to MEDS fee schedules and indicates the quantity associated with the procedure code
Special Indicators on Fee Schedules The Max Fee column lists the amount the procedure code will be reimbursed. Some fee schedules may contain special indicators in the Max Fee column. These indicators are: • MP – Indicates that a procedure code is manually priced. No rate will be listed. • PSR – Indicates that the rate for this procedure code is provider specific. No rate will be listed. • BLLACQ - Indicates to Bill Acquisition Cost. This applies to the Optician Fee Schedule (formerly vision) • %BILL – indicate that code pays a percentage of the claim billed amount. This applies to the Physician Surgical fee schedule. Please note you must do a find on the CSV format of “BILL” to locate the code. This value does not appear in the autofilter list if the CSV is filtered. MEDS Specific Values • Lst-15 – Indicates to be priced at the lesser of list minus 15% based on an appropriate published manufacturer's suggested retail price or Medicare Price if
3 available. Appropriate documentation regarding pricing must be available upon request. • Zero - Indicates that a procedure code is manually priced or requires PA. No rate will be listed. • CST+75 – Indicates for a hearing aid repair, the payment for repairs performed by the manufacturer or third party vendor are limited to the manufacturer or third party vendor's actual costs plus $75. Appropriate documentation regarding pricing must be available upon request.
Table Listing The following tables provide fee schedules, rate types and other additional information:
Table 1: The Enhanced Fee Schedule table, is a comprehensive listing of all fee schedules. The Rate Type column provides a 2 or 3 digit character value associated with the specific fee schedule that is used to generate the fee schedule. In a limited number of fee schedules, such as the physician fee schedule, the additional notes column contains specific instructions on how to use the Rate Type column. The Available Format column indicates whether the fee schedule is available in PDF or CSV.
Table 2: The Rate Type table further defines the rate types used in each fee schedule.
Table 3: Lists the Diagnosis Codes for Family Planning Services Table 3a: contains ICD-9-CM codes Table 3b: contains ICD-10-CM codes effective 10/1/2015.
Table 4: The HUSKY Health Primary Care Rates lists the services eligible for enhanced payments under the HUSKY Health Primary Care for services furnished by certain primary care physicians. The rates will be effective 01/01/2015 to 12/31/2299. Please refer to bulletin PB-2014-75, PB-2015-44, PB 2017-44 and PB 2017-72 for further information.
Table 5: Lists the services eligible for enhanced payments under ACA Section 1202 Increased Payments for Services Furnished by Certain Primary Care Physicians
Table 6: Lists Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health.
Table 7: Lists Physician Surgery fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health.
Table 8: Lists Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services for mental health services.
Table 9: Lists the Physician Office and Outpatient codes for OBS (Obstetrical) rate type ICD-10-CM codes effective 10/1/2015.
4
Table 10: Lists the ICD-10-CM Behavioral Health Diagnosis Codes effective 10/1/2015.
Table 11: Lists the ICD-10-CM Pregnancy Diagnosis Codes not requiring PA for Lab Procedures 81220-81224 effective 10/1/2015. Table 11a: Lists ICD-10-CM Diagnosis Codes SMA Lab Procedure 81329 effective 1/1/2021.
Table 12: Lists the ICD-10 CM Diagnosis Codes for Tuberculosis Eligibility Waiver (Reference Provider Bulletin 2011-73) effective 10/1/2015.
Table 13: Lists the Diagnosis Codes for High Risk Obstetrical Radiology Table 13a: contains ICD-9-CM codes effective 7/1/2015 - 9/30/2015 Table 13b: contains ICD-10-CM codes effective 10/1/2015.
Table 14: Kessner Index for Insufficient Prenatal Care. Please refer to policy transmittal, PT-36 Changes to the Obstetric (OBS) and Facility Obstetric (FTO) Rate Types. This table is effective 7/1/2015 forward.
Table 15: Lists Primary Diagnosis Codes for Therapy Audits Requiring Prior Authorization. All Physical Therapy, Occupational Therapy and Speech Pathology Treatment Services in excess of nine treatments per calendar year per provider per client.
Table 16: Contains the diagnosis codes specified in policy transmittal 2015-102 pertaining to procedure code V2025 eyeglasses deluxe frames. Effective 2/1/2016: one of the listed diagnosis codes is required when V2025 is billed.
Table 17: List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Services (2023T and T1017).
Table 18: List of Gender Reassignment Procedure and Surgery Pricing List.
Table 19: List of the Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Table 20: List of codes that are to be used for Chiropractor services.
5 Table Listing, Next Table 2, End of Document
Table 1: Enhanced Fee Schedule Table Note: For special projects the CSV format may be temporarily removed and replaced by a PDF. Once the special project updates are completed, the CSV will then be made available.
Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format Acquired Brain For claims with dates of service 9/1/2016 and after AAB Injury Case CSV PAB Management
Acquired Brain Historical for claims with dates of service prior to 9/1/2016 Injury DOS Prior DEF CSV to 09/01/2016
Acquired Brain For claims with dates of service 9/1/2016 and after DEF CSV Injury Fiduciary
Acquired Brain Historical for claims with dates of service prior to 9/1/2016 Injury II DOS ABI CSV Prior to 09/01/2016
Acquired Brain For claims with dates of service 9/1/2016 and after Injury Service ABI CSV Provider
Formerly Alcohol Treatment - Consolidates the Clinic FAT Ambulatory (Alcohol Treatment) and the Free Standing Inpatient and MAT CSV Detoxification Free Standing Outpatient Fee schedules from the PAT historical version into one fee schedule
Autism Spectrum ASD CSV Disorder
Autism Waiver Fiscal AU2 CSV Intermediary
Autism Waiver AU1 CSV Service Provider
6 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format Effective 10/1/2014, claims billed with facility type code (FTC) 31 or 32 will be paid at a unique rate and identified ASB on the fee schedule with a new rate type of FTD or FTM. DEF Behavioral Health Effective 2/1/2016, claims billed with specified services by FTD CSV Clinician provider type 33 or 86 and 115, 118, 119, or 121 will be FTM paid at a unique rate and identified on the fee schedule MPH with a new rate type of ASB. This code will be designated in the fee schedule footer to disregard the MPH rate until changes are made to display the new ASB rate type.
Chiropractor DEF CSV
Clinic - Ambulatory ASC CSV Surgical Center MM Clinic – Chemical Formerly Clinic - Substance Abuse MMM CSV Maintenance PMM
Formerly Clinic - Mental Health ECC Clinic – Clinic MH Formerly Clinic – Behavioral Health and Outpatient MMH CSV Hospital OEC Behavioral Health OMH PMH
Clinic - Dialysis DC CSV
Clinic Family FP Planning / CSV PFP Abortion
MC Clinic Medical CSV MMC
Clinic - MRC RC CSV Rehabilitation
Community First CFP Choice - CSV PFT Assessments
Community First CFA CSV Choice - Services PFA
7 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format
CHC CT Home Care CSV PCH
DDS Specialized DNH CSV Service NF
Dental Adult DEN CSV
Please note that 1) This fee schedule lists the fees for a client under the age of 21. The fee for a client 21 years of age and older is 52% of the fee listed on this schedule and 2) T1015 may be billed only by FQHCS and pays at the Dental DOS Prior DEN CSV provider specific rate to 09/01/2016 DNA Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright 2008 American Dental Association. All rights reserved. Applicable FARS/DFARS Apply.
Dental Pediatric DEN CSV
Home Health PDF
RCC 657 - Must include a HCPC from the Physician Fee Schedule. Pricing for this code uses the physician fee schedule rate. RCC 658 – Pricing based on the Nursing Home provider DEF Hospice CSV number on the client’s eligibility file. MSA RCC 659 – Must include procedure code S9381. Provider specific rate for add on cost for escort service. Provider must apply to DSS for this rate. Refer to chapter 1 - DSS Directory for rate setting contact information.
OTH Hospital DRG OTK PDF Organ Acquisition OTL OTP
8 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format Hospital DEF Outpatient Flat OCD CSV Fee RCC
Independent Audiology and Speech and AUD CSV Language Pathology
Independent Physical Therapy OT CSV and Occupational PT Therapy
Independent IRA CSV Radiology
Please note: When billing for Physician Lab services, for surgical pathology codes use the Physician Office and Outpatient Fee Schedule with the LAB rate type. For all Lab DEF CSV other Lab codes use the Lab Fee Schedule. Providers must bill their lowest price charged or accepted from any other payer.
Effective 8/26/19, a new Fee Schedule was created. TB Local Health TB CSV rate type was transferred from Special Services to this fee Department schedule.
This fee schedule now incorporates all E codes including MEDS - DME DEF CSV the oxygen codes.
MEDS-Hearing Please note that only one hearing aid or assistive listening Aid/Prosthetic DEF CSV device is allowed in any three-year period. Eye
MEDS-Medical This fee schedule now incorporates all A codes. /Surgical DEF CSV Supplies
MEDS-MISC DEF CSV This fee schedule lists all S codes.
MEDS- This fee schedule incorporates all B codes including the Parenteral- DEF CSV equipment. Enteral
9 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format MEDS-Prosthetic This fee schedule incorporates all L codes. DEF CSV /Orthotic
Mental Health Assisted Living provider type 77 specialty 772 for dates of Waiver Assisted MHW CSV service 2/1/2020 forward Living Provider
Mental Health Documents historical rates for provider type 77 specialty Waiver DOS 770 prior to services requiring a care plan prior to MHW CSV Prior to 2/1/2020 02/01/2020
Service provider type 77 specialty 771 for dates of service Mental Health 2/1/20 forward Waiver Service and Fiscal MHW CSV & Intermediary Fiscal Intermediary provider type 77 specialty 770 for Provider dates of service 2/1/2020 forward
Natureopath PDF
Optician Replaces the historical Vision Fee Schedule OPT CSV /Eyeglasses
Personal Care DEF CSV Assistant PCA
The new format provides the conversion factor and Physician relative value. Anesthesia claims price using the following DEF CSV Anesthesia formula: Anesthesia pricing formula: (units/15 + relative value) x conversion factor.
If the rate type column is equal to PED, pediatric services, or OBS for obstetrical services, this indicates that there is DEF a unique rate for providers submitting these services for FTD qualified clients and claim data. FTL FTO 1. Claim will pay at the OBS rate when the following Physician Office FTP criteria are met: and Outpt FTM CSV • The billing provider is a physician or physician Services LAB group practice with a specialty in family practice or MPH obstetrics and gynecology and has met enrollment OBS requirements. PED • The OBS ICD-10 Diagnosis code must be the primary diagnosis code if claim dates of service are on or after 10/1/2015.
10 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format • The procedure codes have an OBS rate type on the Physician Fee Schedule. • The client is a female and the claim indicates a pregnancy-related ICD-9-CM diagnosis code (630-634.92, 640-676.92, V22-V25.9, V26.3, and V28-V28.9). As of 4/1/2015, the following ICD-9- CM codes will no longer assign an OBS rate type: V25, V25.0, V25.01, V25.02, V25.03, V25.04, V25.09, V25.1, V25.11, V25.12, V25.13, V25.2, V25.3, V25.4, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.8, V25.9. ICD-10-CM diagnosis codes see Table 9.
2. Claim will pay at the PED rate when the following criteria are met: • The billing provider is a physician or physician group practice with a specialty in family practice or pediatrics and has met enrollment requirements. • The procedure codes have a PED rate type on the Physician Fee Schedule. • The client is under the age of 21 on the date of service. 3. Please note: When billing for Physician Lab services, for surgical pathology codes use the Physician Office and Outpatient Fee Schedule with the LAB rate type. For all other Lab codes use the Lab Fee Schedule. For non-FQHC Service Billing: 08/527 Physician Services – Non-mental Health. See the following tables: PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services For non-FQHC Service Billing: 08/528 Physician Services – Mental Health. See the following tables: PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/528 FQHC Billing non_FQHC Services
11 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format Physician Services - Mental Health Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rate and identified on the fee schedule with a new rate type of FTD, FTL, FTM, FTO, or FTP. Effective 1/1/2016, claims billed with FTC 19 will be included.
OBS Physician PRA CSV Radiology RAD
Effective 10/1/2014, claims billed with facility type code FTO (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a FTP unique rate and identified on the fee schedule with a new Physician FTS CSV rate type of FTO, FTP, or FTS. Effective 1/1/2016, claims Surgical OBS billed with FTC 19 will be included. PED SUR
Formerly Behavioral Health Psychologist Effective 10/1/2014, claims billed with facility type code (FTC) of 31 or 32 will be paid at a unique rate and ASP identified on the fee schedule with a new rate type of FTD DEF or FTM Psychologist FTD CSV Effective 2/1/2016, claims billed with specified services by FTM provider type 33 or 86 and provider specialty 112 will be MPH paid at a unique rate and identified on the fee schedule with a new rate type of ASP. This code will be designated in the fee schedule footer to disregard the MPH rate until changes are made to display the new ASP rate. PSS Effective 8/26/19, TB rate type was moved to the new Special Services SS CSV Local Health Department fee schedule TB Special Services B3 CSV Birth to Three yrs
Target Case Management TCM CSV Non-Contracted
Transportation - DEF CSV Air Ambulance
12 Table 1 Enhanced Fee Schedule Table Rate Type(s) Available Fee Schedule Additional Notes on CSV Format format Transportation - DEF CSV Basic/Advanced
Transportation - Critical DEF CSV Helicopter
Transportation - Non-emergency NET CSV Medical
Transportation - DEF CSV Travel Agent
Table Listing, Previous Table 1, Next Table 3a, End of Document
Table 2: Rate Types
Table 2 Rate Types
Rate Type Rate Type Description AAB ABI Initial Assessment ABI ABI II ASB Autism Spectrum Disorder for BH Clinician ASC Ambulatory Surgical Center ASD Autism Spectrum Disorder ASP Autism Spectrum Disorder for Psychologist AU1 Autism Service Provider AU2 Autism Fiscal Intermediary AUD Audiology BAT Behavioral Health Alcohol Treatment BFQ Behavioral Health FQHC (Federally Qualified Health Center) BHH Behavioral Health Home Health BHO Behavioral Health Hospital BHP Behavioral Health Hospital for APC BMC Behavioral Health Medical Clinic BMH Behavioral Health Mental Health BMM Behavioral Health Methadone Maintenance BPA Provider Specific Rate Behavioral Health Alcohol
13 Table 2 Rate Types
Rate Type Rate Type Description BPB Provider Specific Rate Behavioral Health Methadone Maintenance BPH Behavioral Health Physician BPM Provider Specific Rate Behavioral Health Mental Health BPS Provider Specific Rate Behavioral Health Special Service BRC Behavioral Health Rehabilitation Center BSS Behavioral Health Special Service B3 Birth to Three CF Outpatient Child First, limited to specified providers CFA Community First Choice Access Agency CFP Community First Choice PCA Services CHC CHC (Connecticut Home Care) Home Health DC Dialysis Center DEF Default- the BASE Rate for a Procedure code DEN Dental DMR Department of Mental Retardation/Department of Mental Health DNA Dental Adult DNH DDS/NH Clients ECC Enhanced Care Clinic FAT Alcohol Treatment FP Family Planning Facility Default Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTD Effective 1/1/2016, claims billed with FTC 19 will be included. Facility Lab Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTL Effective 1/1/2016, claims billed with FTC 19 will be included. Facility Melded Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTM Effective 1/1/2016, claims billed with FTC 19 will be included. Facility Obstetrical Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTO Effective 1/1/2016, claims billed with FTC 19 will be included. Facility Pediatrician Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTP Effective 1/1/2016, claims billed with FTC 19 will be included. Facility Surgical Effective 10/1/2014, claims billed with facility type code (FTC) of 21, 22, 23, 24, 25, 31, or 32 will be paid at a unique rates. FTS Effective 1/1/2016, claims billed with FTC 19 will be included. HH Home Health HOL Hospital Lab INL Independent Lab IRA Independent Radiology
14 Table 2 Rate Types
Rate Type Rate Type Description LAB Physician Lab LBP Lab Billed by Physician MAT Melded Alcohol Treatment MC Medical Clinic MFQ Melded Clinic FQHC MH Mental Health MHW Mental Health Waiver MM Methadone Maintenance MMC Melded Medical Clinic MMH Melded Mental Health MMM Melded Methadone Maintenance MOP Melded Outpatient MPH Melded Physician MRC Melded Rehab Clinic MSA Hospice MSA NET Non-emergency Medical Transportation OBS Obstetrical OCD Outpt CD 01/019 ODS Outpt Dental Surge OEC Outpatient ECC OMH Outpatient Mental Health OPT Vision Care OT Occupational Therapy OTH Organ Transplant Heart OTK Organ Transplant Kidney OTL Organ Transplant Liver OTP Organ Transplant Pancreas PAB ABI PSR Case Management PAT Provider Specific Rate Alcohol Treatment PCA Personal Care Assistant PCH Provider Specific Rate CT Home Care PED Pediatric PFA Provider Specific Rate Community First Choice Assessment PFP Provider Specific Rate Family Planning PFT Provider Specific Rate Community First Choice PCA or other services PMC Provider Specific Rate Medical Clinic PMH Provider Specific Rate Mental Health PMM Provider Specific Rate Methadone Maintenance PRA Physician Radiology PRC Provider Specific Rate Rehab Center
15 Table 2 Rate Types
Rate Type Rate Type Description PSC Provider Specific Rate Surgical Center PSS Provider Specific Rate Special Services PT Physical Therapy RAD APC Radiology RC Rehabilitation Center RCC RCC Flat Fee REP Durable Medical Equipment Replacement SS Special Services SUR Surgical TB TB - PT/PS 22/202 TCM TCM Non Contracted VIS Vision
Table Listing, Previous Table 2, Next Table 3b, End of Document
Table 3: Family Planning Services
Table 3a: ICD-9-CM Diagnosis Codes for Family Planning Services
Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 042 Human immunodeficiency virus [HIV] disease 054.0 Eczema herpeticum 054.1 Herpes simplex; Genital herpes 054.10 Genital herpes, unspecified 054.11 Herpetic vulvovaginitis 054.12 Herpetic ulceration of vulva 054.13 Herpetic infection of penis 054.19 Other genital herpes 054.5 Herpetic septicemia 054.6 Herpetic whitlow
16 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 054.9 Herpes simplex without mention of complication 078 Other diseases due to viruses and Chlamydiae 078.0 Molluscum contagiosum 078.1 Other diseases due to viruses and Chlamydiae; Viral warts 078.10 Viral warts, unspecified 078.11 Condyloma acuminatum 078.19 Other specified viral warts 078.88 Other specified diseases due to chlamydiae 079.4 Human papillomavirus in conditions classified elsewhere and of unspecified site 079.53 Human immunodeficiency virus, type 2 [HIV-2] 079.88 Other specified chlamydial infection 079.98 Unspecified chlamydial infection 079.99 Unspecified viral infection 091.0 Genital syphilis (primary) 091.1 Primary anal syphilis 091.2 Other primary syphilis 091.3 Secondary syphilis of skin or mucous membranes 091.4 Adenopathy due to secondary syphilis 091.5 Early syphilis, symptomatic; Uveitis due to secondary syphilis 091.50 Syphilitic uveitis, unspecified 091.51 Syphilitic chorioretinitis (secondary) 091.52 Syphilitic iridocyclitis (secondary) 091.6 Early syphilis, symptomatic; Secondary syphilis of viscera and bone 091.61 Secondary syphilitic periostitis 091.62 Secondary syphilitic hepatitis 091.69 Secondary syphilis of other viscera 091.7 Secondary syphilis, relapse 091.8 Early syphilis, symptomatic; Other forms of secondary syphilis 091.81 Acute syphilitic meningitis (secondary) 091.82 Syphilitic alopecia 091.89 Other forms of secondary syphilis
17 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 091.9 Unspecified secondary syphilis 092.0 Early syphilis, latent, serological relapse after treatment 092.9 Early syphilis, latent, unspecified 096 Late syphilis, latent 097.0 Late syphilis, unspecified 097.1 Latent syphilis, unspecified 097.9 Syphilis, unspecified 098.0 Gonococcal infection (acute) of lower genitourinary tract 098.1 Gonococcal infections; Acute, of upper genitourinary tract 098.10 Gonococcal infection (acute) of upper genitourinary tract, site unspecified 098.11 Gonococcal cystitis (acute) 098.12 Gonococcal prostatitis (acute) 098.13 Gonococcal epididymo-orchitis (acute) 098.14 Gonococcal seminal vesiculitis (acute) 098.15 Gonococcal cervicitis (acute) 098.16 Gonococcal endometritis (acute) 098.17 Gonococcal salpingitis, specified as acute 098.19 Other gonococcal infection (acute) of upper genitourinary tract 098.2 Gonococcal infection, chronic, of lower genitourinary tract 098.30 Chronic gonococcal infection of upper genitourinary tract, site unspecified 098.31 Gonococcal cystitis, chronic 098.32 Gonococcal prostatitis, chronic 098.33 Gonococcal epididymo-orchitis, chronic 098.34 Gonococcal seminal vesiculitis, chronic 098.35 Gonococcal cervicitis, chronic 098.36 Gonococcal endometritis, chronic 098.37 Gonococcal salpingitis (chronic) 098.39 Other chronic gonococcal infection of upper genitourinary tract 098.6 Gonococcal infection of pharynx 098.7 Gonococcal infection of anus and rectum 099.0 Chancroid
18 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 099.1 Lymphogranuloma venereum 099.2 Granuloma inguinale 099.40 Other nongonococcal urethritis, unspecified 099.41 Other nongonococcal urethritis, chlamydia trachomatis 099.49 Other nongonococcal urethritis, other specified organism 099.50 Other venereal diseases due to chlamydia trachomatis, unspecified site 099.51 Other venereal diseases due to chlamydia trachomatis, pharynx 099.52 Other venereal diseases due to chlamydia trachomatis, anus and rectum 099.53 Other venereal diseases due to chlamydia trachomatis, lower genitourinary sites 099.54 Other venereal diseases due to chlamydia trachomatis, other genitourinary sites 099.55 Other venereal diseases due to chlamydia trachomatis, unspecified genitourinary site 099.56 Other venereal diseases due to chlamydia trachomatis, peritoneum 099.59 Other venereal diseases due to chlamydia trachomatis, other specified site 099.8 Other specified venereal diseases 099.9 Venereal disease, unspecified 112.1 Candidiasis of vulva and vagina 112.2 Candidiasis of other urogenital sites 131.00 Urogenital trichomoniasis, unspecified 131.01 Trichomonal vulvovaginitis 131.02 Trichomonal urethritis 131.03 Trichomonal prostatitis 131.09 Other urogenital trichomoniasis 132.2 Phthirus pubis [pubic louse] 233.1 Carcinoma in situ of cervix uteri 599.0 Urinary tract infection, site not specified 608.89 Other specified disorders of male genital organs 614.3 Acute parametritis and pelvic cellulitis 616.0 Cervicitis and endocervicitis 616.1 Inflammatory disease of cervix, vagina, and vulva; Vaginitis and vulvovaginitis 616.10 Vaginitis and vulvovaginitis, unspecified 616.2 Cyst of Bartholin's gland
19 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 616.3 Abscess of Bartholin's gland 616.5 Inflammatory disease of cervix, vagina, and vulva; Ulceration of vulva 622.0 Erosion and ectropion of cervix 622.1 Noninflammatory disorders of cervix; Dysplasia of cervix (uteri) 622.11 Mild dysplasia of cervix 622.12 Moderate dysplasia of cervix 623.5 Leukorrhea, not specified as infective 625.9 Unspecified symptom associated with female genital organs 626 Disorders of menstruation and other abnormal bleeding from female genital tract 626.0 Absence of menstruation 626.1 Scanty or infrequent menstruation 626.2 Excessive or frequent menstruation 626.3 Puberty bleeding 626.4 Irregular menstrual cycle 626.6 Metrorrhagia 626.7 Postcoital bleeding 626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract Unspecified disorders of menstruation and other abnormal bleeding from female genital 626.9 tract 698.1 Pruritus of genital organs 788.41 Urinary frequency 788.7 Urethral discharge Other and nonspecific abnormal cytological, histological, immunological and DNA test 795.0 findings; Abnormal Papanicolaou smear of cervix and cervical HPV 795.00 Abnormal glandular Papanicolaou smear of cervix Papanicolaou smear of cervix with atypical squamous cells of undetermined 795.01 significance (ASC-US) Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade 795.02 squamous intraepithelial lesion (ASC-H) 795.03 Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL) 795.04 Papanicolaou smear of cervix with high grade squamous intraepithelial lesion (HGSIL) 795.05 Cervical high risk human papillomavirus (HPV) DNA test positive
20 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 996.32 Mechanical complication due to intrauterine contraceptive device V01.6 Contact with or exposure to venereal diseases V01.79 Contact with or exposure to other viral diseases V25.04 Counseling and instruction in natural family planning to avoid pregnancy V25.09 Other general counseling and advice on contraceptive management Encounter for contraceptive management; Encounter for insertion or removal of V25.1 intrauterine contraceptive device V04.89 Need for prophylactic vaccination and inoculation against other viral diseases V08 Asymptomatic human immunodeficiency virus [HIV] infection status V25.01 General counseling on prescription of oral contraceptives V25.02 General counseling on initiation of other contraceptive measures V25.03 Encounter for emergency contraceptive counseling and prescription V25.11 Encounter for insertion of intrauterine contraceptive device V25.12 Encounter for removal of intrauterine contraceptive device V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device V25.2 Sterilization V25.40 Contraceptive surveillance, unspecified V25.41 Surveillance of contraceptive pill V25.42 Surveillance of intrauterine contraceptive device V25.43 Surveillance of implantable subdermal contraceptive V25.49 Surveillance of other contraceptive method V25.5 Insertion of implantable subdermal contraceptive V25.8 Other specified contraceptive management V25.9 Unspecified contraceptive management V26.51 Tubal ligation status V26.52 Vasectomy status V45.51 Presence of intrauterine contraceptive device V45.52 Presence of subdermal contraceptive implant V45.59 Presence of other contraceptive device V65.44 Human immunodeficiency virus (HIV) counseling V70.0 Routine general medical examination at a health care facility
21 Table 3a Diagnosis Codes for Family Planning Services Use ICD-9- ICD-9-CM descriptions effective through 9/30/2015 CM codes effective through 9/30/2015 V72.31 Routine gynecological examination Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear V72.32 following initial abnormal smear V72.40 Pregnancy examination or test, pregnancy unconfirmed V72.41 Pregnancy examination or test, negative result V72.42 Pregnancy examination or test, positive result V73.81 Special screening examination for Human papillomavirus (HPV) V73.88 Special screening examination for other specified chlamydial diseases V74.5 Screening examination for venereal disease V76.2 Screening for malignant neoplasms of cervix
Table Listing, Previous Table 3a, Next Table 4, End of Document
Table 3b: ICD-10-CM Diagnosis Codes for Family Planning Services
Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes A510 Primary genital syphilis 10/1/2015 12/31/2299 A511 Primary anal syphilis 10/1/2015 12/31/2299 A512 Primary syphilis of other sites 10/1/2015 12/31/2299 A5131 Condyloma latum 10/1/2015 12/31/2299 A5132 Syphilitic alopecia 10/1/2015 12/31/2299 A5139 Other secondary syphilis of skin 10/1/2015 12/31/2299 A5141 Secondary syphilitic meningitis 10/1/2015 12/31/2299 A5142 Secondary syphilitic female pelvic disease 10/1/2015 12/31/2299 A5143 Secondary syphilitic oculopathy 10/1/2015 12/31/2299 A5144 Secondary syphilitic nephritis 10/1/2015 12/31/2299
22 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes A5145 Secondary syphilitic hepatitis 10/1/2015 12/31/2299 A5146 Secondary syphilitic osteopathy 10/1/2015 12/31/2299 A5149 Other secondary syphilitic conditions 10/1/2015 12/31/2299 A515 Early syphilis, latent 10/1/2015 12/31/2299 A519 Early syphilis, unspecified 10/1/2015 12/31/2299 A528 Late syphilis, latent 10/1/2015 12/31/2299 A529 Late syphilis, unspecified 10/1/2015 12/31/2299 A530 Latent syphilis, unspecified as early or late 10/1/2015 12/31/2299 A539 Syphilis, unspecified 10/1/2015 12/31/2299 A5400 Gonococcal infection of lower genitourinary tract, unsp 10/1/2015 12/31/2299 A5401 Gonococcal cystitis and urethritis, unspecified 10/1/2015 12/31/2299 A5402 Gonococcal vulvovaginitis, unspecified 10/1/2015 12/31/2299 A5403 Gonococcal cervicitis, unspecified 10/1/2015 12/31/2299 A5409 Other gonococcal infection of lower genitourinary tract 10/1/2015 12/31/2299 A541 Gonocl infct of lower GU tract w periureth and acc glnd abcs 10/1/2015 12/31/2299 A5421 Gonococcal infection of kidney and ureter 10/1/2015 12/31/2299 A5422 Gonococcal prostatitis 10/1/2015 12/31/2299 A5423 Gonococcal infection of other male genital organs 10/1/2015 12/31/2299 A5424 Gonococcal female pelvic inflammatory disease 10/1/2015 12/31/2299 A5429 Other gonococcal genitourinary infections 10/1/2015 12/31/2299 A545 Gonococcal pharyngitis 10/1/2015 12/31/2299 A546 Gonococcal infection of anus and rectum 10/1/2015 12/31/2299 A55 Chlamydial lymphogranuloma (venereum) 10/1/2015 12/31/2299 A5600 Chlamydial infection of lower genitourinary tract, unsp 10/1/2015 12/31/2299 A5601 Chlamydial cystitis and urethritis 10/1/2015 12/31/2299 A5602 Chlamydial vulvovaginitis 10/1/2015 12/31/2299 A5609 Other chlamydial infection of lower genitourinary tract 10/1/2015 12/31/2299 A5611 Chlamydial female pelvic inflammatory disease 10/1/2015 12/31/2299 A5619 Other chlamydial genitourinary infection 10/1/2015 12/31/2299 A562 Chlamydial infection of genitourinary tract, unspecified 10/1/2015 12/31/2299 A563 Chlamydial infection of anus and rectum 10/1/2015 12/31/2299 A564 Chlamydial infection of pharynx 10/1/2015 12/31/2299
23 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes A568 Sexually transmitted chlamydial infection of other sites 10/1/2015 12/31/2299 A57 Chancroid 10/1/2015 12/31/2299 A58 Granuloma inguinale 10/1/2015 12/31/2299 A5900 Urogenital trichomoniasis, unspecified 10/1/2015 12/31/2299 A5901 Trichomonal vulvovaginitis 10/1/2015 12/31/2299 A5902 Trichomonal prostatitis 10/1/2015 12/31/2299 A5903 Trichomonal cystitis and urethritis 10/1/2015 12/31/2299 A5909 Other urogenital trichomoniasis 10/1/2015 12/31/2299 A6000 Herpesviral infection of urogenital system, unspecified 10/1/2015 12/31/2299 A6001 Herpesviral infection of penis 10/1/2015 12/31/2299 A6002 Herpesviral infection of other male genital organs 10/1/2015 12/31/2299 A6003 Herpesviral cervicitis 10/1/2015 12/31/2299 A6004 Herpesviral vulvovaginitis 10/1/2015 12/31/2299 A6009 Herpesviral infection of other urogenital tract 10/1/2015 12/31/2299 A601 Herpesviral infection of perianal skin and rectum 10/1/2015 12/31/2299 A609 Anogenital herpesviral infection, unspecified 10/1/2015 12/31/2299 A630 Anogenital (venereal) warts 10/1/2015 12/31/2299 A638 Other specified predominantly sexually transmitted diseases 10/1/2015 12/31/2299 A64 Unspecified sexually transmitted disease 10/1/2015 12/31/2299 A7489 Other chlamydial diseases 10/1/2015 12/31/2299 A749 Chlamydial infection, unspecified 10/1/2015 12/31/2299 B000 Eczema herpeticum 10/1/2015 12/31/2299 B007 Disseminated herpesviral disease 10/1/2015 12/31/2299 B0089 Other herpesviral infection 10/1/2015 12/31/2299 B009 Herpesviral infection, unspecified 10/1/2015 12/31/2299 B078 Other viral warts 10/1/2015 12/31/2299 B079 Viral wart, unspecified 10/1/2015 12/31/2299 B081 Molluscum contagiosum 10/1/2015 12/31/2299 B20 Human immunodeficiency virus [HIV] disease 10/1/2015 12/31/2299 B373 Candidiasis of vulva and vagina 10/1/2015 12/31/2299 B3741 Candidal cystitis and urethritis 10/1/2015 12/31/2299 B3742 Candidal balanitis 10/1/2015 12/31/2299
24 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes B3749 Other urogenital candidiasis 10/1/2015 12/31/2299 B853 Phthiriasis 10/1/2015 12/31/2299 B9735 HIV 2 as the cause of diseases classified elsewhere 10/1/2015 12/31/2299 B977 Papillomavirus as the cause of diseases classified elsewhere 10/1/2015 12/31/2299 B9789 Oth viral agents as the cause of diseases classd elswhr 10/1/2015 12/31/2299 D060 Carcinoma in situ of endocervix 10/1/2015 12/31/2299 D061 Carcinoma in situ of exocervix 10/1/2015 12/31/2299 D067 Carcinoma in situ of other parts of cervix 10/1/2015 12/31/2299 D069 Carcinoma in situ of cervix, unspecified 10/1/2015 12/31/2299 L290 Pruritus ani 1/1/2017 12/31/2299 L291 Pruritus scroti 10/1/2015 12/31/2299 L292 Pruritus vulvae 10/1/2015 12/31/2299 L293 Anogenital pruritus, unspecified 10/1/2015 12/31/2299 N341 Nonspecific urethritis 10/1/2015 12/31/2299 N390 Urinary tract infection, site not specified 10/1/2015 12/31/2299 N441 Cyst of tunica albuginea testis 10/1/2015 12/31/2299 N442 Benign cyst of testis 10/1/2015 12/31/2299 N448 Other noninflammatory disorders of the testis 10/1/2015 12/31/2299 N503 Cyst of epididymis 10/1/2015 12/31/2299 N508 Other specified disorders of male genital organs 10/1/2015 9/30/2016 N5312 Painful ejaculation 10/1/2015 12/31/2299 N72 Inflammatory disease of cervix uteri 10/1/2015 12/31/2299 N730 Acute parametritis and pelvic cellulitis 10/1/2015 12/31/2299 N739 Female pelvic inflammatory disease, unspecified 10/1/2015 12/31/2299 N750 Cyst of Bartholin's gland 10/1/2015 12/31/2299 N751 Abscess of Bartholin's gland 10/1/2015 12/31/2299 N758 Other diseases of Bartholin's gland 10/1/2015 12/31/2299 N760 Acute vaginitis 10/1/2015 12/31/2299 N761 Subacute and chronic vaginitis 10/1/2015 12/31/2299 N762 Acute vulvitis 10/1/2015 12/31/2299 N763 Subacute and chronic vulvitis 10/1/2015 12/31/2299 N766 Ulceration of vulva 10/1/2015 12/31/2299
25 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes N86 Erosion and ectropion of cervix uteri 10/1/2015 12/31/2299 N870 Mild cervical dysplasia 10/1/2015 12/31/2299 N871 Moderate cervical dysplasia 10/1/2015 12/31/2299 N897 Hematocolpos 10/1/2015 12/31/2299 N898 Other specified noninflammatory disorders of vagina 10/1/2015 12/31/2299 N910 Primary amenorrhea 10/1/2015 12/31/2299 N911 Secondary amenorrhea 10/1/2015 12/31/2299 N912 Amenorrhea, unspecified 10/1/2015 12/31/2299 N913 Primary oligomenorrhea 10/1/2015 12/31/2299 N914 Secondary oligomenorrhea 10/1/2015 12/31/2299 N915 Oligomenorrhea, unspecified 10/1/2015 12/31/2299 N920 Excessive and frequent menstruation with regular cycle 10/1/2015 12/31/2299 N921 Excessive and frequent menstruation with irregular cycle 10/1/2015 12/31/2299 N922 Excessive menstruation at puberty 10/1/2015 12/31/2299 N925 Other specified irregular menstruation 10/1/2015 12/31/2299 N926 Irregular menstruation, unspecified 10/1/2015 12/31/2299 N930 Postcoital and contact bleeding 10/1/2015 12/31/2299 N938 Other specified abnormal uterine and vaginal bleeding 10/1/2015 12/31/2299 N939 Abnormal uterine and vaginal bleeding, unspecified 10/1/2015 12/31/2299 N9489 Oth cond assoc w female genital organs and menstrual cycle 10/1/2015 12/31/2299 R102 Pelvic and perineal pain 10/1/2015 12/31/2299 R309 Painful micturition, unspecified 10/1/2015 12/31/2299 R350 Frequency of micturition 10/1/2015 12/31/2299 R360 Urethral discharge without blood 10/1/2015 12/31/2299 R369 Urethral discharge, unspecified 10/1/2015 12/31/2299 R87610 Atyp squam cell of undet signfc cyto smr crvx (ASC-US) 10/1/2015 12/31/2299 R87611 Atyp squam cell not excl hi grd intrepith lesn cyto smr crvx 10/1/2015 12/31/2299 R87612 Low grade intrepith lesion cyto smr crvx (LGSIL) 10/1/2015 12/31/2299 R87613 High grade intrepith lesion cyto smr crvx (HGSIL) 10/1/2015 12/31/2299 R87619 Unsp abnormal cytolog findings in specmn from cervix uteri 10/1/2015 12/31/2299 R87810 Cervical high risk HPV DNA test positive 10/1/2015 12/31/2299 T8331XA Breakdown (mechanical) of intrauterine contracep dev, init 10/1/2015 12/31/2299
26 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes T8332XA Displacement of intrauterine contraceptive device, init 10/1/2015 12/31/2299 T8339XA Mech compl of intrauterine contraceptive device, init encntr 10/1/2015 12/31/2299 Z0000 Encntr for general adult medical exam w/o abnormal findings 10/1/2015 12/31/2299 Z0001 Encounter for general adult medical exam w abnormal findings 10/1/2015 12/31/2299 Z01411 Encntr for gyn exam (general) (routine) w abnormal findings 10/1/2015 12/31/2299 Z01419 Encntr for gyn exam (general) (routine) w/o abn findings 10/1/2015 12/31/2299 Z0142 Encntr for cerv smear to cnfrm norm smr fol init abn smear 10/1/2015 12/31/2299 Z113 Encntr screen for infections w sexl mode of transmiss 10/1/2015 12/31/2299 Z114 Encounter for screening for human immunodeficiency virus 10/1/2015 12/31/2299 Z1151 Encounter for screening for human papillomavirus (HPV) 10/1/2015 12/31/2299 Z118 Encounter for screening for oth infec/parastc diseases 10/1/2015 12/31/2299 Z124 Encounter for screening for malignant neoplasm of cervix 10/1/2015 12/31/2299 Z202 Contact w and exposure to infect w a sexl mode of transmiss 10/1/2015 12/31/2299 Z205 Contact with and (suspected) exposure to viral hepatitis 10/1/2015 12/31/2299 Z206 Contact w and (suspected) exposure to human immunodef virus 10/1/2015 12/31/2299 Z20828 Contact w and exposure to oth viral communicable diseases 10/1/2015 12/31/2299 Z21 Asymptomatic human immunodeficiency virus infection status 10/1/2015 12/31/2299 Z23 Encounter for immunization 10/1/2015 12/31/2299 Z30011 Encounter for initial prescription of contraceptive pills 10/1/2015 12/31/2299 Z30012 Encounter for prescription of emergency contraception 10/1/2015 12/31/2299 Z30013 Encounter for initial prescription of injectable contracep 10/1/2015 12/31/2299 Z30014 Encounter for initial prescription of uterin contracep dev 10/1/2015 12/31/2299 Z30015 Encounter for initial prescription of vagnl ring 10/1/2016 12/31/2299 Z30016 Enctr for init prescription of patch hormonal contracep dev 10/1/2016 12/31/2299 Z30017 Enctr for init prescription of implntbl subdermal contracep 10/1/2016 12/31/2299 Z30018 Encounter for initial prescription of other contraceptives 10/1/2015 12/31/2299 Z30019 Encounter for initial prescription of contraceptives, unsp 10/1/2015 12/31/2299 Z3002 Cnsl and instruction in natrl family planning to avoid preg 10/1/2015 12/31/2299 Z3009 Encounter for oth general cnsl and advice on contraception 10/1/2015 12/31/2299 Z302 Encounter for sterilization 10/1/2015 12/31/2299 Z3040 Encounter for surveillance of contraceptives, unspecified 10/1/2015 12/31/2299 Z3041 Encounter for surveillance of contraceptive pills 10/1/2015 12/31/2299
27 Table 3b Diagnosis Codes for Family Planning Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes Z3042 Encounter for surveillance of injectable contraceptive 10/1/2015 12/31/2299 Z30430 Encounter for insertion of intrauterine contraceptive device 10/1/2015 12/31/2299 Z30431 Encounter for routine checking of intrauterine contracep dev 10/1/2015 12/31/2299 Z30432 Encounter for removal of intrauterine contraceptive device 10/1/2015 12/31/2299 Z30433 Encntr for removal and reinsertion of uterin contracep dev 10/1/2015 12/31/2299 Z3044 Encounter for surveillance of vagnl ring 10/1/2016 12/31/2299 Z3045 Enctr srvlnc transdermal patch hormonal contraceptive device 10/1/2016 12/31/2299 Z3046 Enctr srvlnc implantable subdermal contraceptive 10/1/2016 12/31/2299 Z3049 Encounter for surveillance of other contraceptives 10/1/2015 12/31/2299 Z308 Encounter for other contraceptive management 10/1/2015 12/31/2299 Z309 Encounter for contraceptive management, unspecified 10/1/2015 12/31/2299 Z3200 Encounter for pregnancy test, result unknown 10/1/2015 12/31/2299 Z3201 Encounter for pregnancy test, result positive 10/1/2015 12/31/2299 Z3202 Encounter for pregnancy test, result negative 10/1/2015 12/31/2299 Z717 Human immunodeficiency virus [HIV] counseling 10/1/2015 12/31/2299 Z975 Presence of (intrauterine) contraceptive device 10/1/2015 12/31/2299 Z9851 Tubal ligation status 10/1/2015 12/31/2299 Z9852 Vasectomy status 10/1/2015 12/31/2299
Table Listing, Previous Table 3b, Next Table 5, End of Document
Table 4: HUSKY Health Primary Care Rates
HUSKY Health Primary Care Rates Table 4 (effective 01/01/2015 to 12/31/2299) Facility Rate Non-Facility Facility Rate Non-Facility Non-Facility Facility Rate 12/01/17 - Rate 08/11/17 - Proc Rate Rate 01/01/15 - Procedure Code Description 12/31/2299 08/11/17 – 11/30/17 Code 12/01/17 - 01/01/15 - 08/10/17 11/30/17 08/10/17 12/31/2299 90460 IM ADMIN 1ST/ONLY COMPONENT $22.24 - $21.07 - $23.41 - 90471 IMMUNIZATION ADMINISTRATION $26.28 - $24.89 - $27.66 - 90472 IMMUNIZATION ADMIN EACH ADD $12.95 - $12.27 - $13.63 - 90473 IMMUNIZATION ADMINISTRATION $24.89 - $27.66 - BY $26.28 -
28 HUSKY Health Primary Care Rates Table 4 (effective 01/01/2015 to 12/31/2299) Facility Rate Non-Facility Facility Rate Non-Facility Non-Facility Facility Rate 12/01/17 - Rate 08/11/17 - Proc Rate Rate 01/01/15 - Procedure Code Description 12/31/2299 08/11/17 – 11/30/17 Code 12/01/17 - 01/01/15 - 08/10/17 11/30/17 12/31/2299 08/10/17 90474 IMMUNIZATION ADMINISTRATION $12.27 - $13.63 - BY $12.95 - 99201 OFFICE/OUTPATIENT VISIT NEW $44.92 $26.94 $42.55 $25.53 $47.28 $28.36 99202 OFFICE/OUTPATIENT VISIT NEW $76.89 $51.27 $72.85 $48.57 $80.94 $53.96 99203 OFFICE/OUTPATIENT VISIT NEW $111.52 $78.26 $105.65 $74.14 $117.39 $82.38 99204 OFFICE/OUTPATIENT VISIT NEW $170.65 $133.94 $161.67 $126.89 $179.63 $140.99 99205 OFFICE/OUTPATIENT VISIT NEW $212.08 $172.69 $200.92 $163.60 $223.24 $181.78 99211 OFFICE/OUTPATIENT VISIT EST $20.89 $9.41 $19.79 $8.92 $21.99 $9.91 99212 OFFICE/OUTPATIENT VISIT EST $45.30 $25.80 $42.91 $24.44 $47.68 $27.15 99213 OFFICE/OUTPATIENT VISIT EST $75.23 $52.29 $71.27 $49.54 $79.19 $55.04 99214 OFFICE/OUTPATIENT VISIT EST $110.77 $80.18 $104.94 $75.96 $116.60 $84.40 99215 OFFICE/OUTPATIENT VISIT EST $147.97 $112.80 $140.18 $106.86 $155.76 $118.73 99304 NURSING FACILITY CARE INIT $95.16 - $90.15 - $100.17 - 99305 NURSING FACILITY CARE INIT $135.60 - $128.47 - $142.74 - 99306 NURSING FACILITY CARE INIT $171.34 - $162.32 - $180.36 - 99307 NURSING FAC CARE SUBSEQ $45.56 - $43.16 - $47.96 - 99308 NURSING FAC CARE SUBSEQ $70.42 - $66.72 - $74.13 - 99309 NURSING FAC CARE SUBSEQ $92.56 - $87.69 - $97.43 - 99310 NURSING FAC CARE SUBSEQ $137.66 - $130.41 - $144.90 - 99315 NURSING FACILITY DISCHARGE $70.75 - $78.61 - DAY MANAGEMEN $74.68 - 99316 NURSING FACILITY DISCHARGE $101.21 - $112.46 - DAY MANAGEMEN $106.84 - 99318 ANNUAL NURSING FAC $92.73 - $103.03 - ASSESSMNT $97.88 - 99324 DOMICIL/R-HOME VISIT NEW PAT $56.74 - $53.76 - $59.73 - 99325 DOMICIL/R-HOME VISIT NEW PAT $82.41 - $78.08 - $86.75 - 99326 DOMICIL/R-HOME VISIT NEW PAT $141.83 - $134.36 - $149.29 - 99327 DOMICIL/R-HOME VISIT NEW PAT $189.54 - $179.57 - $199.52 - 99328 DOMICIL/R-HOME VISIT NEW PAT $219.37 - $207.83 - $230.92 - 99334 DOMICIL/R-HOME VISIT EST PAT $61.91 - $58.65 - $65.17 - 99335 DOMICIL/R-HOME VISIT EST PAT $96.70 - $91.61 - $101.79 - 99336 DOMICIL/R-HOME VISIT EST PAT $136.16 - $129.00 - $143.33 - 99337 DOMICIL/R-HOME VISIT EST PAT $196.47 - $186.13 - $206.81 - 99339 INDIVIDUAL PHYSICIAN $75.91 - $84.34 - SUPERVISION OF A PA $80.12 - 99341 HOME VISIT NEW PATIENT $56.36 - $53.40 - $59.33 - 99342 HOME VISIT NEW PATIENT $81.31 - $77.03 - $85.59 -
29 HUSKY Health Primary Care Rates Table 4 (effective 01/01/2015 to 12/31/2299) Facility Rate Non-Facility Facility Rate Non-Facility Non-Facility Facility Rate 12/01/17 - Rate 08/11/17 - Proc Rate Rate 01/01/15 - Procedure Code Description 12/31/2299 08/11/17 – 11/30/17 Code 12/01/17 - 01/01/15 - 08/10/17 11/30/17 08/10/17 12/31/2299 99343 HOME VISIT NEW PATIENT $132.66 - $125.68 - $139.64 - 99344 HOME VISIT NEW PATIENT $185.59 - $175.82 - $195.36 - 99345 HOME VISIT NEW PATIENT $223.66 - $211.89 - $235.43 - 99347 HOME VISIT EST PATIENT $56.78 - $53.79 - $59.77 - 99348 HOME VISIT EST PATIENT $85.73 - $81.22 - $90.24 - 99349 HOME VISIT EST PATIENT $129.68 - $122.86 - $136.51 - 99350 HOME VISIT EST PATIENT $180.94 - $171.41 - $190.46 - 99381 INIT PM E/M NEW PAT INFANT $114.21 - $108.20 - $120.22 - 99382 INIT PM E/M NEW PAT 1-4 YRS $118.83 - $112.57 - $125.08 - 99383 PREV VISIT NEW AGE 5-11 $123.91 - $117.39 - $130.43 - 99384 PREV VISIT NEW AGE 12-17 $139.87 - $132.51 - $147.23 - 99385 PREV VISIT NEW AGE 18-39 $135.92 - $128.76 - $143.07 - 99386 PREV VISIT NEW AGE 40-64 $156.49 - $148.26 - $164.73 - 99387 INIT PM E/M NEW PAT 65+ YRS $170.19 - $161.24 - $179.15 - 99391 PER PM REEVAL EST PAT INFANT $102.73 - $97.33 - $108.14 - 99392 PREV VISIT EST AGE 1-4 $109.62 - $103.85 - $115.39 - 99393 PREV VISIT EST AGE 5-11 $109.24 - $103.49 - $114.99 - 99394 PREV VISIT EST AGE 12-17 $119.32 - $113.04 - $125.60 - 99395 PREV VISIT EST AGE 18-39 $121.84 - $115.43 - $128.25 - 99396 PREV VISIT EST AGE 40-64 $129.82 - $122.99 - $136.65 - 99397 PER PM REEVAL EST PAT 65+ YR $139.87 - $132.51 - $147.23 - 99401 PREVENTIVE COUNSELING INDIV $37.61 - $35.63 - $39.59 - 99402 PREVENTIVE COUNSELING INDIV $64.11 - $60.73 - $67.48 - 99403 PREVENTIVE COUNSELING INDIV $89.10 - $84.41 - $93.79 - 99404 PREVENTIVE COUNSELING INDIV $113.98 - $107.98 - $119.98 - 99406 BEHAV CHNG SMOKING 3-10 MIN $13.45 $11.81 $14.94 $13.12 $14.19 $12.47 99407 BEHAV CHNG SMOKING > 10 MIN $26.51 $26.47 $26.51 $25.08 $29.46 $27.86 99408 AUDIT/DAST 15-30 MIN $35.97 - $34.07 - $37.86 - 99409 AUDIT/DAST OVER 30 MIN $70.02 - $66.34 - $73.71 - 99411 PREVENTIVE COUNSELING $16.25 - $18.06 - GROUP $17.16 - 99412 PREVENTIVE COUNSELING $21.02 - $23.36 - GROUP $22.19 -
30 Table Listing, Previous Table 4, Next Table 6, End of Document
Table 5: 2013 / 2014 Fee Table for ACA Section 1202 The fee table below lists the services eligible for enhanced payments under ACA Section 1202 Increased Payments for Services Furnished by Certain Primary Care Physicians. The non-facility 2013 column is effective for dates of service 1/1/2013 – 12/31/2013 and the new non-facility 2014 column is effective for dates of service 1/1/2014 – 12/31/2014. The fees below will pay only when the services are provided by an enrolled, eligible provider. For all non-eligible providers and non-eligible services please continue to refer to the physician office and outpatient fee schedule. Fees are effective retroactive to dates of service 1/1/2013 for approved attestations submitted prior to April 1, 2013. For approved attestations submitted April 1st and later, the effective date for the enhanced fees is based on the date of attestation. For more information regarding provider eligibility and ACA Section 1202 Increased Payments for Services Furnished by Certain Primary Care Physicians please refer to PB 2013-08 and PB 2013-37.
Table 5 2014 Fee Table for ACA Section 1202 Proc Non-Facility 2014 Procedure Code Description Non-Facility 2013 Code Non-Facility 90460 IM ADMIN 1ST/ONLY COMPONENT $ 23.41 $ 23.41 90471 IMMUNIZATION ADMINISTRATION $ 29.95 $ 27.66 90472 IMMUNIZATION ADMIN EACH ADD $ 14.40 $ 13.63 90473 IMMUNIZATION ADMINISTRATION BY $ 29.95 $ 27.66 90474 IMMUNIZATION ADMINISTRATION BY $ 14.40 $ 13.63 99201 OFFICE/OUTPATIENT VISIT, NEW $ 50.33 $ 47.28 99202 OFFICE/OUTPATIENT VISIT, NEW $ 85.10 $ 80.93 99203 OFFICE/OUTPATIENT VISIT, NEW $ 123.53 $ 117.40 99204 OFFICE/OUTPATIENT VISIT, NEW $ 187.26 $ 179.63 99205 OFFICE/OUTPATIENT VISIT, NEW $ 231.19 $ 223.23 99211 OFFICE/OUTPATIENT VISIT, EST $ 23.51 $ 21.99 99212 OFFICE/OUTPATIENT VISIT, EST $ 50.33 $ 47.68 99213 OFFICE/OUTPATIENT VISIT, EST $ 82.98 $ 79.19 99214 OFFICE/OUTPATIENT VISIT, EST $ 121.50 $ 116.60 99215 OFFICE/OUTPATIENT VISIT, EST $ 162.23 $ 155.76 99217 OBSERVATION CARE DISCHARGE $ 79.66 $ 77.81 99218 INITIAL OBSERVATION CARE $ 108.29 $ 106.00 99219 INITIAL OBSERVATION CARE $ 147.64 $ 145.00 99220 INITIAL OBSERVATION CARE $ 202.62 $ 198.47
31 Table 5 2014 Fee Table for ACA Section 1202 Proc Non-Facility 2014 Procedure Code Description Non-Facility 2013 Code Non-Facility 99221 INITIAL HOSPITAL CARE $ 111.75 $ 109.07 99222 INITIAL HOSPITAL CARE $ 151.43 $ 148.00 99223 INITIAL HOSPITAL CARE $ 222.33 $ 217.81 99231 SUBSEQUENT HOSPITAL CARE $ 42.71 $ 41.96 99232 SUBSEQUENT HOSPITAL CARE $ 78.52 $ 77.03 99233 SUBSEQUENT HOSPITAL CARE $ 113.24 $ 110.96 99234 OBSERV/HOSP SAME DATE $ 147.58 $ 144.95 99235 OBSERV/HOSP SAME DATE $ 184.30 $ 180.93 99236 OBSERV/HOSP SAME DATE $ 238.09 $ 233.59 99238 HOSPITAL DISCHARGE DAY $ 79.61 $ 77.76 99239 HOSPITAL DISCHARGE DAY $ 117.91 $ 114.92 99241 OFFICE CONSULTATION $ 53.17 $ 53.32 99242 OFFICE CONSULTATION $ 99.76 $ 99.55 99243 OFFICE CONSULTATION $ 135.90 $ 135.76 99244 OFFICE CONSULTATION $ 199.80 $ 199.77 99245 OFFICE CONSULTATION $ 244.23 $ 244.27 99251 INPATIENT CONSULTATION $ 52.87 $ 52.93 99252 INPATIENT CONSULTATION $ 81.56 $ 81.22 99253 INPATIENT CONSULTATION $ 124.14 $ 123.88 99254 INPATIENT CONSULTATION $ 178.77 $ 178.58 99255 INPATIENT CONSULTATION $ 223.27 $ 215.93 99281 EMERGENCY DEPT VISIT $ 22.76 $ 22.38 99282 EMERGENCY DEPT VISIT $ 44.83 $ 44.07 99283 EMERGENCY DEPT VISIT $ 66.75 $ 65.61 99284 EMERGENCY DEPT VISIT $ 127.96 $ 125.23 99285 Emergency Dept Visit $ 186.93 $ 183.84 99291 Critical Care, First Hour $ 307.84 $ 295.20 99292 Critical Care Addl 30 Min $ 135.95 $ 131.72 99304 Nursing Facility Care, Init $ 103.24 $ 100.16 99305 Nursing Facility Care, Init $ 146.54 $ 142.74 99306 Nursing Facility Care, Init $ 184.91 $ 180.36 99307 Nursing Fac Care, Subseq $ 49.07 $ 47.96
32 Table 5 2014 Fee Table for ACA Section 1202 Proc Non-Facility 2014 Procedure Code Description Non-Facility 2013 Code Non-Facility 99308 Nursing Fac Care, Subseq $ 76.39 $ 74.13 99309 Nursing Fac Care, Subseq $ 100.04 $ 97.43 99310 Nursing Fac Care, Subseq $ 149.08 $ 144.90 99315 Nursing Fac Discharge Day $ 80.46 $ 78.61 99316 Nursing Fac Discharge Day $ 115.06 $ 112.46 99318 Annual Nursing Fac Assessmnt $ 105.24 $ 103.02 99324 Domicil/R-Home Visit New Pat $ 61.24 $ 59.74 99325 Domicil/R-Home Visit New Pat $ 88.22 $ 86.75 99326 Domicil/R-Home Visit New Pat $ 152.70 $ 149.29 99327 Domicil/R-Home Visit New Pat $ 204.04 $ 199.52 99328 Domicil/R-Home Visit New Pat $ 236.61 $ 230.92 99334 Domicil/R-Home Visit Est Pat $ 66.66 $ 65.17 99335 Domicil/R-Home Visit Est Pat $ 104.00 $ 101.78 99336 Domicil/R-Home Visit Est Pat $ 147.53 $ 143.33 99337 Domicil/R-Home Visit Est Pat $ 211.32 $ 206.81 99339 Domicil/R-Home Care Supervis $ 86.56 $ 84.34 99341 Home Visit, New Patient $ 60.84 $ 59.33 99342 Home Visit, New Patient $ 87.46 $ 85.59 99343 Home Visit, New Patient $ 143.49 $ 139.64 99344 Home Visit, New Patient $ 199.89 $ 195.36 99345 Home Visit, New Patient $ 240.70 $ 235.43 99347 Home Visit, Est Patient $ 61.27 $ 59.77 99348 Home Visit, Est Patient $ 92.49 $ 90.24 99349 Home Visit, Est Patient $ 140.33 $ 136.52 99350 Home Visit, Est Patient $ 194.99 $ 190.46 99354 Prolonged Service, Office $ 109.50 $ 107.30 99355 Prolonged Service, Office $ 107.10 $ 104.88 99356 Prolonged Service, Inpatient $ 100.48 $ 98.64 99357 Prolonged Service, Inpatient $ 100.08 $ 97.83 99363 Anticoag Mgmt, Init $ 145.10 $ 138.69 99364 Anticoag Mgmt, Subseq $ 48.67 $ 46.78 99374 Home Health Care Supervision $ 78.17 $ 75.94
33 Table 5 2014 Fee Table for ACA Section 1202 Proc Non-Facility 2014 Procedure Code Description Non-Facility 2013 Code Non-Facility 99377 Hospice Care Supervision $ 78.17 $ 75.94 99379 Nursing Fac Care Supervision $ 78.17 $ 75.94 99380 Nursing Fac Care Supervision $ 116.83 $ 113.87 99381 Init Pm E/M, New Pat, Inf $ 125.11 $ 120.22 99382 Init Pm E/M, New Pat 1-4 Yrs $ 129.95 $ 125.08 99383 Prev Visit, New, Age 5-11 $ 135.30 $ 130.43 99384 Prev Visit, New, Age 12-17 $ 152.91 $ 147.23 99385 Prev Visit, New, Age 18-39 $ 148.36 $ 143.07 99386 Prev Visit, New, Age 40-64 $ 171.20 $ 164.73 99387 Init Pm E/M, New Pat 65+ Yrs $ 185.98 $ 179.15 99391 Per Pm Reeval, Est Pat, Inf $ 112.25 $ 108.14 99392 Prev Visit, Est, Age 1-4 $ 119.90 $ 115.39 99393 Prev Visit, Est, Age 5-11 $ 119.50 $ 114.99 99394 Prev Visit, Est, Age 12-17 $ 130.09 $ 125.60 99395 Prev Visit, Est, Age 18-39 $ 132.74 $ 128.25 99396 Prev Visit, Est, Age 40-64 $ 141.57 $ 136.65 99397 Per Pm Reeval Est Pat 65+ Yr $ 152.91 $ 147.23 99401 Preventive Counseling, Indiv $ 41.08 $ 39.59 99402 Preventive Counseling, Indiv $ 69.34 $ 67.48 99403 Preventive Counseling, Indiv $ 96.40 $ 93.79 99404 Preventive Counseling, Indiv $ 123.00 $ 119.98 99406 Behav Chng Smoking 3-10 Min $ 15.71 $ 14.94 99407 Behav Chng Smoking > 10 Min $ 30.21 $ 29.46 99408 Audit/Dast, 15-30 Min $ 38.60 $ 37.86 99409 Audit/Dast, Over 30 Min $ 74.80 $ 73.71 99411 Preventive Counseling, Group $ 19.20 $ 18.06 99412 Preventive Counseling, Group $ 24.49 $ 23.36 99460 Init Nb Em Per Day, Hosp $ 98.89 $ 100.63 99461 Init Nb Em Per Day, Non-Fac $ 113.76 $ 106.85 99462 Sbsq Nb Em Per Day, Hosp $ 45.26 $ 44.92 99463 Same Day Nb Discharge $ 126.40 $ 122.61 99464 Attendance At Delivery $ 83.34 $ 75.42
34 Table 5 2014 Fee Table for ACA Section 1202 Proc Non-Facility 2014 Procedure Code Description Non-Facility 2013 Code Non-Facility 99465 Nb Resuscitation $ 160.45 $ 157.81 99466 Ped Crit Care Transport $ 300.01 $ 285.33 99467 Ped Crit Care Transport Addl $ 133.71 $ 131.45 99468 Neonate Crit Care, Initial $ 1,048.92 $ 997.87 99469 Neonate Crit Care, Subsq $ 429.90 $ 421.57 99471 Ped Critical Care, Initial $ 936.39 $ 914.10 99472 Ped Critical Care, Subsq $ 444.18 $ 429.07 99475 Ped Crit Care Age 2-5, Init $ 617.13 $ 616.61 99476 Ped Crit Care Age 2-5, Subsq $ 382.95 $ 372.98 99477 Init Day Hosp Neonate Care $ 382.75 $ 369.94 99478 Ic, Lbw Inf < 1500 Gm Subsq $ 154.02 $ 146.96 99479 Ic Lbw Inf 1500-2500 G Subsq $ 139.90 $ 133.22 99480 Ic Inf Pbw 2501-5000 G Subsq $ 130.59 $ 128.32
Table Listing, Previous Table 5, Next Table 7, End of Document
Table 6: Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health
Table 6 PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, 32 (7/1/2014 - 12/31/2299) All codes in Table. FTC 19 as of 1/1/2016.
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 99217 Observation care discharge 99218 Initial observation care 99219 Initial observation care 99220 Initial observation care
35
Table 6 PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, 32 (7/1/2014 - 12/31/2299) All codes in Table. FTC 19 as of 1/1/2016.
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 99221 Initial hospital care 99222 Initial hospital care 99223 Initial hospital care 99231 Subsequent hospital care 99232 Subsequent hospital care 99233 Subsequent hospital care 99234 Observ/hosp same date 99235 Observ/hosp same date 99236 Observ/hosp same date 99238 Hospital discharge day management; 30 mi 99239 Hospital discharge day management; more 99251 Inpatient consultation 99252 Inpatient consultation 99253 Inpatient consultation 99254 Inpatient consultation 99255 Inpatient consultation 99281 Emergency dept visit 99282 Emergency dept visit 99283 Emergency dept visit 99284 Emergency dept visit 99285 Emergency dept visit 99291 Critical care first hour 99292 Critical care addl 30 min 99304 Nursing facility care init 99305 Nursing facility care init 99306 Nursing facility care init 99307 Nursing fac care subseq 99308 Nursing fac care subseq
36
Table 6 PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, 32 (7/1/2014 - 12/31/2299) All codes in Table. FTC 19 as of 1/1/2016.
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 99309 Nursing fac care subseq 99310 Nursing fac care subseq 99315 Nursing facility discharge day managemen 99316 Nursing facility discharge day managemen 99374 Home health care supervision 99377 Hospice care supervision 99379 Nursing fac care supervision 99380 Nursing fac care supervision 99460 Init nb em per day hosp 99462 Sbsq nb em per day hosp 99463 Same day nb discharge 99464 Attendance at delivery 99465 Nb resuscitation 99466 Ped crit care transport 99467 Ped crit care transport addl 99468 Neonate crit care initial 99469 Neonate crit care subsq 99471 Ped critical care initial 99472 Ped critical care subsq 99475 Ped crit care age 2-5 init 99476 Ped crit care age 2-5 subsq 99477 Init day hosp neonate care 99478 Ic lbw inf < 1500 gm subsq 99479 Ic lbw inf 1500-2500 g subsq 99480 Ic inf pbw 2501-5000 g subsq
37 Table Listing, Previous Table 6, Next Table 8, End of Document
Table 7: Physician Surgery fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services physician services - non-mental health
Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 11976 Remove contraceptive capsule 11981 Insertion non-biodegradable drug delive 11982 Remove drug implant device 11983 Remove/insert drug implant 43235 Egd diagnostic brush wash 43239 Egd biopsy single/multiple 43243 Egd injection varices 43244 Egd varices ligation 43246 Egd place gastrostomy tube 43247 Egd remove foreign body 43249 Esoph egd dilation <30 mm 43251 Egd remove lesion snare 43255 Egd control bleeding any 43270 Egd lesion ablation 45378 Diagnostic colonoscopy 45379 Colonoscopy w/fb removal 45379 Colonoscopy w/fb removal 45380 Colonoscopy and biopsy 45381 Colonoscopy submucous njx 45384 Colonoscopy w/lesion removal 45385 Colonoscopy w/lesion removal 45388 Colonoscopy w/ablation 46600 Diagnostic anoscopy 49000 Exploratory laparotomy exploratory celi 49255 Omentectomy epiploectomy resection of 49320 Laparoscopy abdomen peritoneum and om
38 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 49321 Laparoscopy biopsy 49322 Laparoscopy aspiration 56405 Incision and drainage of vulva or perine 56420 Drainage of gland abscess 56440 Surgery for vulva lesion 56441 Lysis of labial adhesions 56442 Hymenotomy simple incision 56501 Destroy vulva lesions sim 56515 Destruction of lesion(s) vulva; extensi 56605 Biopsy of vulva or perineum (separate pr 56606 Biopsy of vulva or perineum (separate pr 56620 Vulvectomy simple; partial 56625 Vulvectomy simple; complete 56630 Vulvectomy radical partial; 56631 Vulvectomy radical partial; with unila 56632 Vulvectomy radical partial; with bilat 56633 Vulvectomy radical complete; 56634 Vulvectomy radical complete; with unil 56637 Vulvectomy radical complete; with bila 56640 Vulvectomy radical complete with ingu 56700 Partial hymenectomy or revision of hymen 56740 Remove vagina gland lesion 56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state 56810 Perineoplasty repair of perineum nonob 56820 Colposcopy of the vulva; 56821 Colposcopy of the vulva; with biopsy(s) 57000 Colpotomy; with exploration 57010 Colpotomy; with drainage of pelvic absce 57020 Colpocentesis (separate procedure) 57022 I & d vaginal hematoma pp 57023 I & d vag hematoma non-ob
39 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 57061 Destroy vag lesions simple 57065 Destroy vag lesions complex 57100 Biopsy of vaginal mucosa; simple (separa 57105 Biopsy of vaginal mucosa; extensive req 57106 Remove vagina wall partial 57107 Remove vagina tissue part 57109 Vaginectomy partial removal of vaginal 57110 Remove vagina wall complete 57111 Remove vagina tissue compl 57112 Vaginectomy w/nodes compl 57120 Colpocleisis (le fort type) 57130 Excision of vaginal septum 57135 Excision of vaginal cyst or tumor 57150 Irrigation of vagina and/or application 57155 Insert uteri tandem/ovoids 57156 Ins vag brachytx device 57160 Fitting and insertion of pessary or othe 57170 Diaphragm or cervical cap fitting with i 57180 Introduction of any hemostatic agent or 57200 Colporrhaphy suture of injury of vagina 57210 Colpoperineorrhaphy suture of injury of 57220 Plastic operation on urethral sphincter 57230 Plastic repair of urethrocele 57240 Anterior colporrhaphy repair of cystoce 57250 Posterior colporrhaphy repair of rectoc 57260 Combined anteroposterior colporrhaphy; 57265 Combined anteroposterior colporrhaphy; w 57267 Insertion of mesh or other prosthesis fo 57268 Repair of enterocele vaginal approach ( 57270 Repair of enterocele abdominal approach 57280 Colpopexy abdominal approach 57282 Colpopexy extraperitoneal
40 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 57283 Colpopexy intraperitoneal 57284 Repair paravag defect open 57285 Repair paravag defect vag 57287 Removal or revision of sling for stress 57288 Sling operation for stress incontinence 57289 Pereyra procedure including anterior co 57291 Construction of artificial vagina; witho 57292 Construction of artificial vagina; with 57295 Revise vag graft via vagina 57296 Revise vag graft open abd 57300 Closure of rectovaginal fistula; vaginal 57305 Closure of rectovaginal fistula; abdomen 57307 Closure of rectovaginal fistula; abdomen 57308 Fistula repair transperine 57310 Closure of urethrovaginal fistula; 57311 Closure of urethrovaginal fistula; with 57320 Closure of vesicovaginal fistula; vagina 57330 Closure of vesicovaginal fistula; transv 57335 Vaginoplasty for intersex state 57400 Dilation of vagina 57410 Pelvic examination 57415 Remove vaginal foreign body 57420 Colposcopy of the entire vagina with ce 57421 Colposcopy of the entire vagina with ce 57423 Repair paravag defect lap 57425 Laparoscopy surg colpopexy 57426 Revise prosth vag graft lap 57452 Colposcopy (vaginoscopy); (separate proc 57454 Colposcopy (vaginoscopy); with biopsy(s) 57455 Colposcopy of the cervix including upper 57456 Colposcopy of the cervix including upper 57460 Bx of cervix w/scope leep
41 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 57461 Conz of cervix w/scope leep 57500 Biopsy of cervix 57505 Endocervical curettage (not done as part 57510 Cautery of cervix; electro or thermal 57511 Cauterization of cervix; cryocautery in 57513 Cauterization of cervix; laser ablation/ 57520 Conization of cervix with or without fu 57522 Conization of cervix with or without fu 57530 Trachelectomy (cervicectomy) amputation 57531 Removal of cervix radical 57540 Excision of cervical stump abdominal ap 57545 Excision of cervical stump abdominal ap 57550 Excision of cervical stump vaginal appr 57555 Excision of cervical stump vaginal appr 57556 Remove cervix repair bowel 57558 Dilation and curettage of cervical stump 57700 Cerclage of uterine cervix nonobstetric 57720 Trachelorrhaphy plastic repair of uteri 57800 Dilation of cervical canal instrumental 58100 Endometrial sampling (biopsy) with or wi 58110 Endometrial sampling (biopsy) performed 58120 Dilation and curettage diagnostic and/o 58140 Myomectomy abdom method 58145 Myomectomy vag method 58146 Myomectomy excision of fibroid tumor(s) 58150 Total abdominal hysterectomy (corpus and 58152 Total abdominal hysterectomy (corpus and 58180 Supracervical abdominal hysterectomy (su 58200 Total abdominal hysterectomy including 58210 Radical abdominal hysterectomy with bil 58240 Pelvic exenteration for gynecologic mali 58260 Vaginal hysterectomy for uterus 250 gra
42 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 58262 Vaginal hysterectomy for uterus 250 gra 58263 Vaginal hysterectomy for uterus 250 gra 58267 Vaginal hysterectomy for uterus 250 gra 58270 Vaginal hysterectomy for uterus 250 gra 58275 Vaginal hysterectomy with total or part 58280 Vaginal hysterectomy with total or part 58285 Vaginal hysterectomy radical (schauta t 58290 Vaginal hysterectomy for uterus greater 58291 Vag hyst incl t/o complex 58292 Vag hyst t/o & repair compl 58293 Vag hyst w/uro repair compl 58294 Vag hyst w/enterocele compl 58300 Insertion of intrauterine device (iud) 58301 Removal of intrauterine device (iud) 58340 Catheterization and introduction of sali 58345 Transcervical introduction of fallopian 58346 Insertion of heyman capsules for clinica 58350 Chromotubation of oviduct including mat 58353 Endometr ablate thermal 58356 Endometrial cryoablation with ultrasonic 58400 Uterine suspension with or without shor 58410 Uterine suspension with or without shor 58520 Hysterorrhaphy repair of ruptured uteru 58540 Hysteroplasty repair of uterine anomaly 58541 Lsh uterus 250 g or less 58542 Laparoscopy surgical supracervical hys 58543 Laparoscopy surgical supracervical hys 58544 Laparoscopy surgical supracervical hys 58545 Laparoscopy surgical myomectomy excis 58546 Laparo-myomectomy complex 58548 Laparoscopy surgical with radical hyst 58550 Laparoscopy surgical with vaginal hyste
43 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 58552 Laparoscopy surgical with vaginal hyste 58553 Laparo-vag hyst complex 58554 Laparo-vag hyst w/t/o compl 58555 Hysteroscopy dx sep proc 58558 Hysteroscopy biopsy 58559 Hysteroscopy lysis 58560 Hysteroscopy resect septum 58561 Hysteroscopy remove myoma 58562 Hysteroscopy remove fb 58563 Hysteroscopy ablation 58565 Hysteroscopy sterilization 58570 Tlh uterus 250 g or less 58571 Tlh w/t/o 250 g or less 58572 Tlh uterus over 250 g 58573 Tlh w/t/o uterus over 250 g 58578 Laparo proc uterus 58579 Unlisted hysteroscopy procedure uterus 58600 Ligation or transection of fallopian tub 58605 Ligation or transection of fallopian tub 58611 Ligation or transection of fallopian tub 58615 Occlusion of fallopian tube(s) by device 58660 Laparoscopy lysis 58661 Laparoscopy remove adnexa 58662 Laparoscopy excise lesions 58670 Laparoscopy tubal cautery 58671 Laparoscopy tubal block 58672 Laparoscopy fimbrioplasty 58673 Laparoscopy salpingostomy 58679 Laparo proc oviduct-ovary 58700 Salpingectomy complete or partial unil 58720 Salpingo-oophorectomy complete or parti 58740 Adhesiolysis tube ovary
44 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 58750 Tubotubal anastomosis 58752 Tubouterine implantation 58760 Fimbrioplasty 58770 Salpingostomy (salpingoneostomy) 58800 Drainage of ovarian cyst(s) unilateral 58805 Drainage of ovarian cyst(s) unilateral 58820 Drain ovary abscess open 58822 Drain ovary abscess percut 58825 Transposition ovary(s) 58900 Biopsy of ovary unilateral or bilateral 58920 Wedge resection or bisection of ovary u 58925 Ovarian cystectomy unilateral or bilate 58940 Oophorectomy partial or total unilater 58943 Oophorectomy partial or total unilater 58950 Resection (initial) of ovarian tubal or 58951 Resection of ovarian malignancy with bil 58952 Resection of ovarian tubal or primary p 58953 Tah rad dissect for debulk 58954 Bilateral salpingo-oophorectomy with ome 58956 Bso omentectomy w/tah 58957 Resection (tumor debulking) of recurrent 58958 Resection (tumor debulking) of recurrent 58960 Laparotomy for staging or restaging of 58999 Unlisted procedure female genital syste 59000 Amniocentesis diagnostic 59001 Amniocentesis therapeutic 59012 Fetal cord puncture prenatal 59015 Chorionic villus sampling any method 59020 Fetal contraction stress test 59025 Fetal non-stress test 59030 Fetal scalp blood sampling 59050 Fetal monitoring during labor by consult
45 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 59051 Fetal monitoring during labor by consult 59070 Transabdominal amnioinfusion including 59072 Fetal umbilical cord occlusion includin 59074 Fetal fluid drainage (eg vesicocentesis 59076 Fetal shunt placement w/us 59100 Hysterotomy abdominal (eg for hydatidi 59120 Surgical treatment of ectopic pregnancy; 59121 Surgical treatment of ectopic pregnancy; 59130 Surgical treatment of ectopic pregnancy; 59135 Surgical treatment of ectopic pregnancy; 59136 Surgical treatment of ectopic pregnancy; 59140 Surgical treatment of ectopic pregnancy; 59150 Laparoscopic treatment of ectopic pregna 59151 Laparoscopic treatment of ectopic pregna 59160 Curettage postpartum/currettage postpa 59200 Insertion of cervical dilator (eg lamin 59320 Cerclage of cervix during pregnancy; va 59325 Cerclage of cervix during pregnancy; ab 59350 Hysterorrhaphy of ruptured uterus 59409 Vaginal delivery only (with or without e 59410 Vaginal delivery only (with or without e 59412 External cephalic version with or witho 59414 Delivery of placenta (separate procedure 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59514 Cesarean delivery only; 59515 Cesarean delivery only; including postpa 59525 Subtotal or total hysterectomy after ces 59612 Vaginal delivery only after previous ce 59614 Vaginal delivery only after previous ce 59620 Cesarean delivery only following attemp 59622 Cesarean delivery only following attemp
46 Table 7 PHYSICIAN SURGERY FEE SCHEDULE Procedure Codes Payable for 08/527 FQHC Billing non_FQHC Services Physician Services - Non-Mental Health
PROSPECTIVE: FTC 21, 22, 23, 24, 25, 31, & 32 (7/1/2014-12/31/2299) All codes in Table
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014) Procedure Code Proc description 59812 Treatment of incomplete abortion any tr 59820 Treatment of missed abortion completed 59821 Treatment of missed abortion completed 59830 Treatment of septic abortion completed 59840 Induced abortion by dilation and curett 59841 Induced abortion by dilation and evacua 59850 Induced abortion by one or more intra-a 59851 Induced abortion by one or more intra-a 59852 Induced abortion by one or more intra-a 59855 Induced abortion by one or more vaginal 59856 Induced abortion by one or more vaginal 59857 Induced abortion by one or more vaginal 59866 Multifetal pregnancy reduction(s) (mpr) 59870 Uterine evacuation and curettage for hyd 59871 Removal of cerclage suture under anesthe 59897 Fetal invas px w/us 59898 Laparo proc ob care/deliver 59899 Unlisted procedure maternity care and d
47 Table Listing, Previous Table 7, Next Table 9, End of Document
Table 8: Physician Office and Outpatient fee schedule procedure codes payable for 08/527 FQHC billing non-FQHC services for mental health services
Table 8 PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/528 FQHC Billing non_FQHC Services Physician Services - Mental Health
Prospective: FTC 21, 31, 32 ONLY (7/1/2014 – 12/31/2299)
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014)
Procedure Proc description Code
99217 Observation care discharge 99218 Initial observation care 99219 Initial observation care 99220 Initial observation care 99221 Initial hospital care 99222 Initial hospital care 99223 Initial hospital care 99231 Subsequent hospital care 99232 Subsequent hospital care 99233 Subsequent hospital care 99234 Observ/hosp same date 99235 Observ/hosp same date 99236 Observ/hosp same date 99238 Hospital discharge day management; 30 mi 99239 Hospital discharge day management; more 99251 Inpatient consultation 99252 Inpatient consultation 99253 Inpatient consultation 99254 Inpatient consultation 99255 Inpatient consultation 99304 Nursing facility care init 99305 Nursing facility care init 99306 Nursing facility care init 99307 Nursing fac care subseq 99308 Nursing fac care subseq
48
Table 8 PHYSICIAN OFFICE AND OUTPATIENT FEE SCHEDULE Procedure Codes Payable for 08/528 FQHC Billing non_FQHC Services Physician Services - Mental Health
Prospective: FTC 21, 31, 32 ONLY (7/1/2014 – 12/31/2299)
RETROSPECTIVE: Facility type code (FTC) 21 ONLY (1/1/2012 - 06/30/2014)
Procedure Proc description Code
99309 Nursing fac care subseq 99310 Nursing fac care subseq 99315 Nursing facility discharge day managemen 99316 Nursing facility discharge day management
Table Listing, Previous Table 8, Next Table 10, End of Document
Table 9: Physician Office and Outpatient codes for OBS (Obstetrical) rate type ICD-10-CM codes
Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O000 Abdominal pregnancy 20151001 20160930 O0000 Abdominal pregnancy without intrauterine pregnancy 20161001 22991231 O0001 Abdominal pregnancy with intrauterine pregnancy 20161001 22991231 O001 Tubal pregnancy 20151001 20160930 O0010 Tubal pregnancy without intrauterine pregnancy 20161001 20170930 O00101 Right tubal pregnancy without intrauterine pregnancy 20171001 22991231 O00102 Left tubal pregnancy without intrauterine pregnancy 20171001 22991231 O0011 Tubal pregnancy with intrauterine pregnancy 20161001 20170930 O00111 Right tubal pregnancy with intrauterine pregnancy 20171001 22991231 O00112 Left tubal pregnancy with intrauterine pregnancy 20171001 22991231 O002 Ovarian pregnancy 20151001 20160930 O0020 Ovarian pregnancy without intrauterine pregnancy 20161001 20170930 O00201 Right ovarian pregnancy without intrauterine pregnancy 20171001 22991231
49 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O00202 Left ovarian pregnancy without intrauterine pregnancy 20171001 22991231 O0021 Ovarian pregnancy with intrauterine pregnancy 20161001 20170930 O00211 Right ovarian pregnancy with intrauterine pregnancy 20171001 22991231 O00212 Left ovarian pregnancy with intrauterine pregnancy 20171001 22991231 O008 Other ectopic pregnancy 20151001 20160930 O0080 Other ectopic pregnancy without intrauterine pregnancy 20161001 22991231 O0081 Other ectopic pregnancy with intrauterine pregnancy 20161001 22991231 O009 Ectopic pregnancy, unspecified 20151001 22991231 O010 Classical hydatidiform mole 20151001 22991231 O011 Incomplete and partial hydatidiform mole 20151001 22991231 O019 Hydatidiform mole, unspecified 20151001 22991231 O020 Blighted ovum and nonhydatidiform mole 20151001 22991231 O021 Missed abortion 20151001 22991231 O0281 Inapprop chg quantitav hCG in early pregnancy 20151001 22991231 O0289 Other abnormal products of conception 20151001 22991231 O029 Abnormal product of conception, unspecified 20151001 22991231 O030 Genitl trct and pelvic infection fol incmpl spon abortion 20151001 22991231 O031 Delayed or excessive hemor following incmpl spon abortion 20151001 22991231 O032 Embolism following incomplete spontaneous abortion 20151001 22991231 O0330 Unsp complication following incomplete spontaneous abortion 20151001 22991231 O0331 Shock following incomplete spontaneous abortion 20151001 22991231 O0332 Renal failure following incomplete spontaneous abortion 20151001 22991231 O0333 Metabolic disorder following incomplete spontaneous abortion 20151001 22991231 O0334 Damage to pelvic organs following incomplete spon abortion 20151001 22991231 O0335 Oth venous comp following incomplete spontaneous abortion 20151001 22991231 O0336 Cardiac arrest following incomplete spontaneous abortion 20151001 22991231 O0337 Sepsis following incomplete spontaneous abortion 20151001 22991231 O0338 Urinary tract infection following incomplete spon abortion 20151001 22991231 O0339 Incomplete spontaneous abortion with other complications 20151001 22991231 O034 Incomplete spontaneous abortion without complication 20151001 22991231 O035 Genitl trct and pelvic infct fol complete or unsp spon abort 20151001 22991231 O036 Delayed or excess hemor fol complete or unsp spon abortion 20151001 22991231
50 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O037 Embolism following complete or unsp spontaneous abortion 20151001 22991231 O0380 Unsp comp following complete or unsp spontaneous abortion 20151001 22991231 O0381 Shock following complete or unspecified spontaneous abortion 20151001 22991231 O0382 Renal failure following complete or unsp spon abortion 20151001 22991231 O0383 Metabolic disorder following complete or unsp spon abortion 20151001 22991231 O0384 Damage to pelvic organs fol complete or unsp spon abortion 20151001 22991231 O0385 Oth venous comp following complete or unsp spon abortion 20151001 22991231 O0386 Cardiac arrest following complete or unsp spon abortion 20151001 22991231 O0387 Sepsis following complete or unsp spontaneous abortion 20151001 22991231 O0388 Urinary tract infection fol complete or unsp spon abortion 20151001 22991231 O0389 Complete or unsp spontaneous abortion with oth complications 20151001 22991231 O039 Complete or unsp spontaneous abortion without complication 20151001 22991231 O0900 Suprvsn of preg w history of infertility, unsp trimester 20151001 22991231 O0901 Suprvsn of preg w history of infertility, first trimester 20151001 22991231 O0902 Suprvsn of preg w history of infertility, second trimester 20151001 22991231 O0903 Suprvsn of preg w history of infertility, third trimester 20151001 22991231 O0910 Suprvsn of preg with history of ectopic preg, unsp trimester 20151001 22991231 O0911 Suprvsn of preg with history of ectopic preg, first tri 20151001 22991231 O0912 Suprvsn of preg with history of ectopic preg, second tri 20151001 22991231 O0913 Suprvsn of preg with history of ectopic preg, third tri 20151001 22991231 O09211 Suprvsn of preg w history of pre-term labor, first trimester 20151001 22991231 O09212 Suprvsn of preg w history of pre-term labor, second tri 20151001 22991231 O09213 Suprvsn of preg w history of pre-term labor, third trimester 20151001 22991231 O09219 Suprvsn of preg w history of pre-term labor, unsp trimester 20151001 22991231 O09291 Suprvsn of preg w poor reprodctv or obstet hx, first tri 20151001 22991231 O09292 Suprvsn of preg w poor reprodctv or obstet hx, second tri 20151001 22991231 O09293 Suprvsn of preg w poor reprodctv or obstet hx, third tri 20151001 22991231 O09299 Suprvsn of preg w poor reprodctv or obstet history, unsp tri 20151001 22991231 O0930 Suprvsn of preg w insufficient antenat care, unsp trimester 20151001 22991231 O0931 Suprvsn of preg w insufficient antenat care, first trimester 20151001 22991231 O0932 Suprvsn of preg w insufficient antenat care, second tri 20151001 22991231 O0933 Suprvsn of preg w insufficient antenat care, third trimester 20151001 22991231
51 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O0940 Supervision of pregnancy w grand multiparity, unsp trimester 20151001 22991231 O0941 Suprvsn of pregnancy w grand multiparity, first trimester 20151001 22991231 O0942 Suprvsn of pregnancy w grand multiparity, second trimester 20151001 22991231 O0943 Suprvsn of pregnancy w grand multiparity, third trimester 20151001 22991231 O09511 Supervision of elderly primigravida, first trimester 20151001 22991231 O09512 Supervision of elderly primigravida, second trimester 20151001 22991231 O09513 Supervision of elderly primigravida, third trimester 20151001 22991231 O09519 Supervision of elderly primigravida, unspecified trimester 20151001 22991231 O09521 Supervision of elderly multigravida, first trimester 20151001 22991231 O09522 Supervision of elderly multigravida, second trimester 20151001 22991231 O09523 Supervision of elderly multigravida, third trimester 20151001 22991231 O09529 Supervision of elderly multigravida, unspecified trimester 20151001 22991231 O09611 Supervision of young primigravida, first trimester 20151001 22991231 O09612 Supervision of young primigravida, second trimester 20151001 22991231 O09613 Supervision of young primigravida, third trimester 20151001 22991231 O09619 Supervision of young primigravida, unspecified trimester 20151001 22991231 O09621 Supervision of young multigravida, first trimester 20151001 22991231 O09622 Supervision of young multigravida, second trimester 20151001 22991231 O09623 Supervision of young multigravida, third trimester 20151001 22991231 O09629 Supervision of young multigravida, unspecified trimester 20151001 22991231 O0970 Suprvsn of high risk preg due to social problems, unsp tri 20151001 22991231 O0971 Suprvsn of high risk preg due to social problems, first tri 20151001 22991231 O0972 Suprvsn of high risk preg due to social problems, second tri 20151001 22991231 O0973 Suprvsn of high risk preg due to social problems, third tri 20151001 22991231 O09811 Suprvsn of preg rslt from assisted reprodctv tech, first tri 20151001 22991231 O09812 Suprvsn of preg rslt from assist reprodctv tech, second tri 20151001 22991231 O09813 Suprvsn of preg rslt from assisted reprodctv tech, third tri 20151001 22991231 O09819 Suprvsn of preg rslt from assisted reprodctv tech, unsp tri 20151001 22991231 O09821 Suprvsn of preg w hx of in utero proc dur prev preg, 1st tri 20151001 22991231 O09822 Suprvsn of preg w hx of in utero proc dur prev preg, 2nd tri 20151001 22991231 O09823 Suprvsn of preg w hx of in utero proc dur prev preg, 3rd tri 20151001 22991231 O09829 Suprvsn of preg w hx of in utero proc dur prev preg,unsp tri 20151001 22991231
52 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O09891 Supervision of other high risk pregnancies, first trimester 20151001 22991231 O09892 Supervision of other high risk pregnancies, second trimester 20151001 22991231 O09893 Supervision of other high risk pregnancies, third trimester 20151001 22991231 O09899 Supervision of other high risk pregnancies, unsp trimester 20151001 22991231 O0990 Supervision of high risk pregnancy, unsp, unsp trimester 20151001 22991231 O0991 Supervision of high risk pregnancy, unsp, first trimester 20151001 22991231 O0992 Supervision of high risk pregnancy, unsp, second trimester 20151001 22991231 O0993 Supervision of high risk pregnancy, unsp, third trimester 20151001 22991231 O09A1 Suprvsn of preg with history of molar preg, first trimester 20161001 22991231 O09A2 Suprvsn of preg with history of molar preg, second trimester 20161001 22991231 O09A3 Suprvsn of preg with history of molar preg, third trimester 20161001 22991231 O10011 Pre-existing essential htn comp pregnancy, first trimester 20151001 22991231 O10012 Pre-existing essential htn comp pregnancy, second trimester 20151001 22991231 O10013 Pre-existing essential htn comp pregnancy, third trimester 20151001 22991231 O10019 Pre-existing essential htn comp pregnancy, unsp trimester 20151001 22991231 O1002 Pre-existing essential hypertension complicating childbirth 20151001 22991231 O1003 Pre-existing essential hypertension comp the puerperium 20151001 22991231 O10111 Pre-exist hyp heart disease comp pregnancy, first trimester 20151001 22991231 O10112 Pre-exist hyp heart disease comp pregnancy, second trimester 20151001 22991231 O10113 Pre-exist hyp heart disease comp pregnancy, third trimester 20151001 22991231 O10119 Pre-exist hyp heart disease comp pregnancy, unsp trimester 20151001 22991231 O1012 Pre-existing hypertensive heart disease comp childbirth 20151001 22991231 O1013 Pre-existing hypertensive heart disease comp the puerperium 20151001 22991231 O10211 Pre-exist hyp chronic kidney disease comp preg, first tri 20151001 22991231 O10212 Pre-exist hyp chronic kidney disease comp preg, second tri 20151001 22991231 O10213 Pre-exist hyp chronic kidney disease comp preg, third tri 20151001 22991231 O10219 Pre-exist hyp chronic kidney disease comp preg, unsp tri 20151001 22991231 O1022 Pre-existing hyp chronic kidney disease comp childbirth 20151001 22991231 O1023 Pre-existing hyp chronic kidney disease comp the puerperium 20151001 22991231 O10311 Pre-exist hyp heart and chr kidney dis comp preg, first tri 20151001 22991231 O10312 Pre-exist hyp heart and chr kidney dis comp preg, second tri 20151001 22991231 O10313 Pre-exist hyp heart and chr kidney dis comp preg, third tri 20151001 22991231
53 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O10319 Pre-exist hyp heart and chr kidney dis comp preg, unsp tri 20151001 22991231 O1032 Pre-exist hyp heart and chronic kidney disease comp chldbrth 20151001 22991231 O1033 Pre-exist hyp heart and chr kidney disease comp the puerp 20151001 22991231 O10411 Pre-existing secondary htn comp pregnancy, first trimester 20151001 22991231 O10412 Pre-existing secondary htn comp pregnancy, second trimester 20151001 22991231 O10413 Pre-existing secondary htn comp pregnancy, third trimester 20151001 22991231 O10419 Pre-existing secondary htn comp pregnancy, unsp trimester 20151001 22991231 O1042 Pre-existing secondary hypertension complicating childbirth 20151001 22991231 O1043 Pre-existing secondary hypertension comp the puerperium 20151001 22991231 O10911 Unsp pre-existing htn comp pregnancy, first trimester 20151001 22991231 O10912 Unsp pre-existing htn comp pregnancy, second trimester 20151001 22991231 O10913 Unsp pre-existing htn comp pregnancy, third trimester 20151001 22991231 O10919 Unsp pre-existing htn comp pregnancy, unsp trimester 20151001 22991231 O1092 Unsp pre-existing hypertension complicating childbirth 20151001 22991231 O1093 Unsp pre-existing hypertension complicating the puerperium 20151001 22991231 O111 Pre-existing hypertension w pre-eclampsia, first trimester 20151001 22991231 O112 Pre-existing hypertension w pre-eclampsia, second trimester 20151001 22991231 O113 Pre-existing hypertension w pre-eclampsia, third trimester 20151001 22991231 O114 Pre-existing htn with pre-eclampsia, comp childbirth 20161001 22991231 O115 Pre-existing htn with pre-eclampsia, comp the puerperium 20161001 22991231 O119 Pre-existing hypertension with pre-eclampsia, unsp trimester 20151001 22991231 O1200 Gestational edema, unspecified trimester 20151001 22991231 O1201 Gestational edema, first trimester 20151001 22991231 O1202 Gestational edema, second trimester 20151001 22991231 O1203 Gestational edema, third trimester 20151001 22991231 O1204 Gestational edema, complicating childbirth 20161001 22991231 O1205 Gestational edema, complicating the puerperium 20161001 22991231 O1210 Gestational proteinuria, unspecified trimester 20151001 22991231 O1211 Gestational proteinuria, first trimester 20151001 22991231 O1212 Gestational proteinuria, second trimester 20151001 22991231 O1213 Gestational proteinuria, third trimester 20151001 22991231 O1214 Gestational proteinuria, complicating childbirth 20161001 22991231
54 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O1215 Gestational proteinuria, complicating the puerperium 20161001 22991231 O1220 Gestational edema with proteinuria, unspecified trimester 20151001 22991231 O1221 Gestational edema with proteinuria, first trimester 20151001 22991231 O1222 Gestational edema with proteinuria, second trimester 20151001 22991231 O1223 Gestational edema with proteinuria, third trimester 20151001 22991231 O1224 Gestational edema with proteinuria, complicating childbirth 20161001 22991231 O1225 Gestational edema with proteinuria, comp the puerperium 20161001 22991231 O131 Gestational htn w/o significant proteinuria, first trimester 20151001 22991231 O132 Gestatnl htn w/o significant proteinuria, second trimester 20151001 22991231 O133 Gestational htn w/o significant proteinuria, third trimester 20151001 22991231 O134 Gestatnl htn without significant protein, comp childbirth 20161001 22991231 O135 Gestatnl htn without significant protein, comp the puerp 20161001 22991231 O139 Gestational htn w/o significant proteinuria, unsp trimester 20151001 22991231 O1400 Mild to moderate pre-eclampsia, unspecified trimester 20151001 22991231 O1402 Mild to moderate pre-eclampsia, second trimester 20151001 22991231 O1403 Mild to moderate pre-eclampsia, third trimester 20151001 22991231 O1404 Mild to moderate pre-eclampsia, complicating childbirth 20161001 22991231 O1405 Mild to moderate pre-eclampsia, complicating the puerperium 20161001 22991231 O1410 Severe pre-eclampsia, unspecified trimester 20151001 22991231 O1412 Severe pre-eclampsia, second trimester 20151001 22991231 O1413 Severe pre-eclampsia, third trimester 20151001 22991231 O1414 Severe pre-eclampsia complicating childbirth 20161001 22991231 O1415 Severe pre-eclampsia, complicating the puerperium 20161001 22991231 O1420 HELLP syndrome (HELLP), unspecified trimester 20151001 22991231 O1422 HELLP syndrome (HELLP), second trimester 20151001 22991231 O1423 HELLP syndrome (HELLP), third trimester 20151001 22991231 O1424 HELLP syndrome, complicating childbirth 20161001 22991231 O1425 HELLP syndrome, complicating the puerperium 20161001 22991231 O1490 Unspecified pre-eclampsia, unspecified trimester 20151001 22991231 O1492 Unspecified pre-eclampsia, second trimester 20151001 22991231 O1493 Unspecified pre-eclampsia, third trimester 20151001 22991231 O1494 Unspecified pre-eclampsia, complicating childbirth 20161001 22991231
55 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O1495 Unspecified pre-eclampsia, complicating the puerperium 20161001 22991231 O1500 Eclampsia complicating pregnancy, unspecified trimester 20151001 22991231 O1502 Eclampsia complicating pregnancy, second trimester 20151001 22991231 O1503 Eclampsia complicating pregnancy, third trimester 20151001 22991231 O151 Eclampsia complicating labor 20151001 22991231 O152 Eclampsia complicating the puerperium 20151001 22991231 O159 Eclampsia, unspecified as to time period 20151001 22991231 O161 Unspecified maternal hypertension, first trimester 20151001 22991231 O162 Unspecified maternal hypertension, second trimester 20151001 22991231 O163 Unspecified maternal hypertension, third trimester 20151001 22991231 O164 Unspecified maternal hypertension, complicating childbirth 20161001 22991231 O165 Unspecified maternal hypertension, comp the puerperium 20161001 22991231 O169 Unspecified maternal hypertension, unspecified trimester 20151001 22991231 O200 Threatened abortion 20151001 22991231 O208 Other hemorrhage in early pregnancy 20151001 22991231 O209 Hemorrhage in early pregnancy, unspecified 20151001 22991231 O210 Mild hyperemesis gravidarum 20151001 22991231 O211 Hyperemesis gravidarum with metabolic disturbance 20151001 22991231 O212 Late vomiting of pregnancy 20151001 22991231 O218 Other vomiting complicating pregnancy 20151001 22991231 O219 Vomiting of pregnancy, unspecified 20151001 22991231 O2200 Varicose veins of low extrm in pregnancy, unsp trimester 20151001 22991231 O2201 Varicose veins of low extrm in pregnancy, first trimester 20151001 22991231 O2202 Varicose veins of low extrm in pregnancy, second trimester 20151001 22991231 O2203 Varicose veins of low extrm in pregnancy, third trimester 20151001 22991231 O2210 Genital varices in pregnancy, unspecified trimester 20151001 22991231 O2211 Genital varices in pregnancy, first trimester 20151001 22991231 O2212 Genital varices in pregnancy, second trimester 20151001 22991231 O2213 Genital varices in pregnancy, third trimester 20151001 22991231 O2220 Superficial thrombophlebitis in pregnancy, unsp trimester 20151001 22991231 O2221 Superficial thrombophlebitis in pregnancy, first trimester 20151001 22991231 O2222 Superficial thrombophlebitis in pregnancy, second trimester 20151001 22991231
56 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O2223 Superficial thrombophlebitis in pregnancy, third trimester 20151001 22991231 O2230 Deep phlebothrombosis in pregnancy, unspecified trimester 20151001 22991231 O2231 Deep phlebothrombosis in pregnancy, first trimester 20151001 22991231 O2232 Deep phlebothrombosis in pregnancy, second trimester 20151001 22991231 O2233 Deep phlebothrombosis in pregnancy, third trimester 20151001 22991231 O2240 Hemorrhoids in pregnancy, unspecified trimester 20151001 22991231 O2241 Hemorrhoids in pregnancy, first trimester 20151001 22991231 O2242 Hemorrhoids in pregnancy, second trimester 20151001 22991231 O2243 Hemorrhoids in pregnancy, third trimester 20151001 22991231 O2250 Cerebral venous thrombosis in pregnancy, unsp trimester 20151001 22991231 O2251 Cerebral venous thrombosis in pregnancy, first trimester 20151001 22991231 O2252 Cerebral venous thrombosis in pregnancy, second trimester 20151001 22991231 O2253 Cerebral venous thrombosis in pregnancy, third trimester 20151001 22991231 O228X1 Other venous complications in pregnancy, first trimester 20151001 22991231 O228X2 Other venous complications in pregnancy, second trimester 20151001 22991231 O228X3 Other venous complications in pregnancy, third trimester 20151001 22991231 O228X9 Other venous complications in pregnancy, unsp trimester 20151001 22991231 O2290 Venous complication in pregnancy, unsp, unsp trimester 20151001 22991231 O2291 Venous complication in pregnancy, unsp, first trimester 20151001 22991231 O2292 Venous complication in pregnancy, unsp, second trimester 20151001 22991231 O2293 Venous complication in pregnancy, unsp, third trimester 20151001 22991231 O2300 Infections of kidney in pregnancy, unspecified trimester 20151001 22991231 O2301 Infections of kidney in pregnancy, first trimester 20151001 22991231 O2302 Infections of kidney in pregnancy, second trimester 20151001 22991231 O2303 Infections of kidney in pregnancy, third trimester 20151001 22991231 O2310 Infections of bladder in pregnancy, unspecified trimester 20151001 22991231 O2311 Infections of bladder in pregnancy, first trimester 20151001 22991231 O2312 Infections of bladder in pregnancy, second trimester 20151001 22991231 O2313 Infections of bladder in pregnancy, third trimester 20151001 22991231 O2320 Infections of urethra in pregnancy, unspecified trimester 20151001 22991231 O2321 Infections of urethra in pregnancy, first trimester 20151001 22991231 O2322 Infections of urethra in pregnancy, second trimester 20151001 22991231
57 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O2323 Infections of urethra in pregnancy, third trimester 20151001 22991231 O2330 Infections of prt urinary tract in pregnancy, unsp trimester 20151001 22991231 O2331 Infect of prt urinary tract in pregnancy, first trimester 20151001 22991231 O2332 Infect of prt urinary tract in pregnancy, second trimester 20151001 22991231 O2333 Infect of prt urinary tract in pregnancy, third trimester 20151001 22991231 O2340 Unsp infection of urinary tract in pregnancy, unsp trimester 20151001 22991231 O2341 Unsp infct of urinary tract in pregnancy, first trimester 20151001 22991231 O2342 Unsp infct of urinary tract in pregnancy, second trimester 20151001 22991231 O2343 Unsp infct of urinary tract in pregnancy, third trimester 20151001 22991231 O23511 Infections of cervix in pregnancy, first trimester 20151001 22991231 O23512 Infections of cervix in pregnancy, second trimester 20151001 22991231 O23513 Infections of cervix in pregnancy, third trimester 20151001 22991231 O23519 Infections of cervix in pregnancy, unspecified trimester 20151001 22991231 O23521 Salpingo-oophoritis in pregnancy, first trimester 20151001 22991231 O23522 Salpingo-oophoritis in pregnancy, second trimester 20151001 22991231 O23523 Salpingo-oophoritis in pregnancy, third trimester 20151001 22991231 O23529 Salpingo-oophoritis in pregnancy, unspecified trimester 20151001 22991231 O23591 Infection oth prt genitl trct in pregnancy, first trimester 20151001 22991231 O23592 Infection oth prt genitl trct in pregnancy, second trimester 20151001 22991231 O23593 Infection oth prt genitl trct in pregnancy, third trimester 20151001 22991231 O23599 Infection oth prt genital tract in pregnancy, unsp trimester 20151001 22991231 O2390 Unsp GU tract infection in pregnancy, unsp trimester 20151001 22991231 O2391 Unsp GU tract infection in pregnancy, first trimester 20151001 22991231 O2392 Unsp GU tract infection in pregnancy, second trimester 20151001 22991231 O2393 Unsp GU tract infection in pregnancy, third trimester 20151001 22991231 O24011 Pre-existing type 1 diabetes, in pregnancy, first trimester 20151001 22991231 O24012 Pre-existing type 1 diabetes, in pregnancy, second trimester 20151001 22991231 O24013 Pre-existing type 1 diabetes, in pregnancy, third trimester 20151001 22991231 O24019 Pre-exist type 1 diabetes, in pregnancy, unsp trimester 20151001 22991231 O2402 Pre-existing type 1 diabetes mellitus, in childbirth 20151001 22991231 O2403 Pre-existing type 1 diabetes mellitus, in the puerperium 20151001 22991231 O24111 Pre-existing type 2 diabetes, in pregnancy, first trimester 20151001 22991231
58 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O24112 Pre-existing type 2 diabetes, in pregnancy, second trimester 20151001 22991231 O24113 Pre-existing type 2 diabetes, in pregnancy, third trimester 20151001 22991231 O24119 Pre-exist type 2 diabetes, in pregnancy, unsp trimester 20151001 22991231 O2412 Pre-existing type 2 diabetes mellitus, in childbirth 20151001 22991231 O2413 Pre-existing type 2 diabetes mellitus, in the puerperium 20151001 22991231 O24311 Unsp pre-existing diabetes in pregnancy, first trimester 20151001 22991231 O24312 Unsp pre-existing diabetes in pregnancy, second trimester 20151001 22991231 O24313 Unsp pre-existing diabetes in pregnancy, third trimester 20151001 22991231 O24319 Unsp pre-existing diabetes in pregnancy, unsp trimester 20151001 22991231 O2432 Unspecified pre-existing diabetes mellitus in childbirth 20151001 22991231 O2433 Unspecified pre-existing diabetes mellitus in the puerperium 20151001 22991231 O24410 Gestational diabetes mellitus in pregnancy, diet controlled 20151001 22991231 O24414 Gestational diabetes in pregnancy, insulin controlled 20151001 22991231 O24415 Gestatnl diabetes in preg, ctrl by oral hypoglycemic drugs 20161001 22991231 O24419 Gestational diabetes mellitus in pregnancy, unsp control 20151001 22991231 O24420 Gestational diabetes mellitus in childbirth, diet controlled 20151001 22991231 O24424 Gestational diabetes in childbirth, insulin controlled 20151001 22991231 O24425 Gestatnl diab in chldbrth, ctrl by oral hypoglycemic drugs 20161001 22991231 O24429 Gestational diabetes mellitus in childbirth, unsp control 20151001 22991231 O24430 Gestational diabetes in the puerperium, diet controlled 20151001 22991231 O24434 Gestational diabetes in the puerperium, insulin controlled 20151001 22991231 O24435 Gestatnl diabetes in puerp, ctrl by oral hypoglycemic drugs 20161001 22991231 O24439 Gestational diabetes in the puerperium, unsp control 20151001 22991231 O24811 Oth pre-existing diabetes in pregnancy, first trimester 20151001 22991231 O24812 Oth pre-existing diabetes in pregnancy, second trimester 20151001 22991231 O24813 Oth pre-existing diabetes in pregnancy, third trimester 20151001 22991231 O24819 Oth pre-existing diabetes in pregnancy, unsp trimester 20151001 22991231 O2482 Other pre-existing diabetes mellitus in childbirth 20151001 22991231 O2483 Other pre-existing diabetes mellitus in the puerperium 20151001 22991231 O24911 Unspecified diabetes mellitus in pregnancy, first trimester 20151001 22991231 O24912 Unspecified diabetes mellitus in pregnancy, second trimester 20151001 22991231 O24913 Unspecified diabetes mellitus in pregnancy, third trimester 20151001 22991231
59 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O24919 Unsp diabetes mellitus in pregnancy, unspecified trimester 20151001 22991231 O2492 Unspecified diabetes mellitus in childbirth 20151001 22991231 O2493 Unspecified diabetes mellitus in the puerperium 20151001 22991231 O2510 Malnutrition in pregnancy, unspecified trimester 20151001 22991231 O2511 Malnutrition in pregnancy, first trimester 20151001 22991231 O2512 Malnutrition in pregnancy, second trimester 20151001 22991231 O2513 Malnutrition in pregnancy, third trimester 20151001 22991231 O252 Malnutrition in childbirth 20151001 22991231 O253 Malnutrition in the puerperium 20151001 22991231 O2600 Excessive weight gain in pregnancy, unspecified trimester 20151001 22991231 O2601 Excessive weight gain in pregnancy, first trimester 20151001 22991231 O2602 Excessive weight gain in pregnancy, second trimester 20151001 22991231 O2603 Excessive weight gain in pregnancy, third trimester 20151001 22991231 O2610 Low weight gain in pregnancy, unspecified trimester 20151001 22991231 O2611 Low weight gain in pregnancy, first trimester 20151001 22991231 O2612 Low weight gain in pregnancy, second trimester 20151001 22991231 O2613 Low weight gain in pregnancy, third trimester 20151001 22991231 O2620 Preg care for patient w recurrent preg loss, unsp trimester 20151001 22991231 O2621 Preg care for patient w recurrent preg loss, first trimester 20151001 22991231 O2622 Preg care for patient w recur preg loss, second trimester 20151001 22991231 O2623 Preg care for patient w recurrent preg loss, third trimester 20151001 22991231 O2630 Retained uterin contracep dev in pregnancy, unsp trimester 20151001 22991231 O2631 Retained uterin contracep dev in pregnancy, first trimester 20151001 22991231 O2632 Retained uterin contracep dev in pregnancy, second trimester 20151001 22991231 O2633 Retained uterin contracep dev in pregnancy, third trimester 20151001 22991231 O2640 Herpes gestationis, unspecified trimester 20151001 22991231 O2641 Herpes gestationis, first trimester 20151001 22991231 O2642 Herpes gestationis, second trimester 20151001 22991231 O2643 Herpes gestationis, third trimester 20151001 22991231 O2650 Maternal hypotension syndrome, unspecified trimester 20151001 22991231 O2651 Maternal hypotension syndrome, first trimester 20151001 22991231 O2652 Maternal hypotension syndrome, second trimester 20151001 22991231
60 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O2653 Maternal hypotension syndrome, third trimester 20151001 22991231 O26611 Liver and biliary tract disord in pregnancy, first trimester 20151001 22991231 O26612 Liver and biliary tract disord in preg, second trimester 20151001 22991231 O26613 Liver and biliary tract disord in pregnancy, third trimester 20151001 22991231 O26619 Liver and biliary tract disord in pregnancy, unsp trimester 20151001 22991231 O2662 Liver and biliary tract disorders in childbirth 20151001 22991231 O2663 Liver and biliary tract disorders in the puerperium 20151001 22991231 O26711 Sublux of symphysis (pubis) in pregnancy, first trimester 20151001 22991231 O26712 Sublux of symphysis (pubis) in pregnancy, second trimester 20151001 22991231 O26713 Sublux of symphysis (pubis) in pregnancy, third trimester 20151001 22991231 O26719 Sublux of symphysis (pubis) in pregnancy, unsp trimester 20151001 22991231 O2672 Subluxation of symphysis (pubis) in childbirth 20151001 22991231 O2673 Subluxation of symphysis (pubis) in the puerperium 20151001 22991231 O26811 Pregnancy related exhaustion and fatigue, first trimester 20151001 22991231 O26812 Pregnancy related exhaustion and fatigue, second trimester 20151001 22991231 O26813 Pregnancy related exhaustion and fatigue, third trimester 20151001 22991231 O26819 Pregnancy related exhaustion and fatigue, unsp trimester 20151001 22991231 O26821 Pregnancy related peripheral neuritis, first trimester 20151001 22991231 O26822 Pregnancy related peripheral neuritis, second trimester 20151001 22991231 O26823 Pregnancy related peripheral neuritis, third trimester 20151001 22991231 O26829 Pregnancy related peripheral neuritis, unspecified trimester 20151001 22991231 O26831 Pregnancy related renal disease, first trimester 20151001 22991231 O26832 Pregnancy related renal disease, second trimester 20151001 22991231 O26833 Pregnancy related renal disease, third trimester 20151001 22991231 O26839 Pregnancy related renal disease, unspecified trimester 20151001 22991231 O26841 Uterine size-date discrepancy, first trimester 20151001 22991231 O26842 Uterine size-date discrepancy, second trimester 20151001 22991231 O26843 Uterine size-date discrepancy, third trimester 20151001 22991231 O26849 Uterine size-date discrepancy, unspecified trimester 20151001 22991231 O26851 Spotting complicating pregnancy, first trimester 20151001 22991231 O26852 Spotting complicating pregnancy, second trimester 20151001 22991231 O26853 Spotting complicating pregnancy, third trimester 20151001 22991231
61 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O26859 Spotting complicating pregnancy, unspecified trimester 20151001 22991231 O2686 Pruritic urticarial papules and plaques of pregnancy (PUPPP) 20151001 22991231 O26872 Cervical shortening, second trimester 20151001 22991231 O26873 Cervical shortening, third trimester 20151001 22991231 O26879 Cervical shortening, unspecified trimester 20151001 22991231 O26891 Oth pregnancy related conditions, first trimester 20151001 22991231 O26892 Oth pregnancy related conditions, second trimester 20151001 22991231 O26893 Oth pregnancy related conditions, third trimester 20151001 22991231 O26899 Oth pregnancy related conditions, unspecified trimester 20151001 22991231 O2690 Pregnancy related conditions, unsp, unspecified trimester 20151001 22991231 O2691 Pregnancy related conditions, unspecified, first trimester 20151001 22991231 O2692 Pregnancy related conditions, unspecified, second trimester 20151001 22991231 O2693 Pregnancy related conditions, unspecified, third trimester 20151001 22991231 O29011 Aspirat pneumonitis due to anesth during preg, first tri 20151001 22991231 O29012 Aspirat pneumonitis due to anesth during preg, second tri 20151001 22991231 O29013 Aspirat pneumonitis due to anesth during preg, third tri 20151001 22991231 O29019 Aspirat pneumonitis due to anesth during preg, unsp tri 20151001 22991231 O29021 Pressr collapse of lung due to anesth during preg, first tri 20151001 22991231 O29022 Pressr collapse of lung d/t anesth during preg, second tri 20151001 22991231 O29023 Pressr collapse of lung due to anesth during preg, third tri 20151001 22991231 O29029 Pressr collapse of lung due to anesth during preg, unsp tri 20151001 22991231 O29091 Oth pulmonary comp of anesth during preg, first trimester 20151001 22991231 O29092 Oth pulmonary comp of anesth during preg, second trimester 20151001 22991231 O29093 Oth pulmonary comp of anesth during preg, third trimester 20151001 22991231 O29099 Oth pulmonary comp of anesth during preg, unsp trimester 20151001 22991231 O29111 Cardiac arrest due to anesth during preg, first trimester 20151001 22991231 O29112 Cardiac arrest due to anesth during preg, second trimester 20151001 22991231 O29113 Cardiac arrest due to anesth during preg, third trimester 20151001 22991231 O29119 Cardiac arrest due to anesth during preg, unsp trimester 20151001 22991231 O29121 Cardiac failure due to anesth during preg, first trimester 20151001 22991231 O29122 Cardiac failure due to anesth during preg, second trimester 20151001 22991231 O29123 Cardiac failure due to anesth during preg, third trimester 20151001 22991231
62 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O29129 Cardiac failure due to anesth during preg, unsp trimester 20151001 22991231 O29191 Oth cardiac comp of anesth during pregnancy, first trimester 20151001 22991231 O29192 Oth cardiac comp of anesth during preg, second trimester 20151001 22991231 O29193 Oth cardiac comp of anesth during pregnancy, third trimester 20151001 22991231 O29199 Oth cardiac comp of anesth during pregnancy, unsp trimester 20151001 22991231 O29211 Cerebral anoxia due to anesth during preg, first trimester 20151001 22991231 O29212 Cerebral anoxia due to anesth during preg, second trimester 20151001 22991231 O29213 Cerebral anoxia due to anesth during preg, third trimester 20151001 22991231 O29219 Cerebral anoxia due to anesth during preg, unsp trimester 20151001 22991231 O29291 Oth cnsl comp of anesth during pregnancy, first trimester 20151001 22991231 O29292 Oth cnsl comp of anesth during pregnancy, second trimester 20151001 22991231 O29293 Oth cnsl comp of anesth during pregnancy, third trimester 20151001 22991231 O29299 Oth cnsl comp of anesthesia during pregnancy, unsp trimester 20151001 22991231 O293X1 Toxic reaction to local anesth during preg, first trimester 20151001 22991231 O293X2 Toxic reaction to local anesth during preg, second trimester 20151001 22991231 O293X3 Toxic reaction to local anesth during preg, third trimester 20151001 22991231 O293X9 Toxic reaction to local anesth during preg, unsp trimester 20151001 22991231 O2940 Spinal and epidur anesth induce hdache during preg, unsp tri 20151001 22991231 O2941 Spinal and epidur anesth induce hdache dur preg, first tri 20151001 22991231 O2942 Spinal and epidur anesth induce hdache dur preg, second tri 20151001 22991231 O2943 Spinal and epidur anesth induce hdache dur preg, third tri 20151001 22991231 O295X1 Oth comp of spinal and epidur anesth during preg, first tri 20151001 22991231 O295X2 Oth comp of spinal and epidur anesth during preg, second tri 20151001 22991231 O295X3 Oth comp of spinal and epidur anesth during preg, third tri 20151001 22991231 O295X9 Oth comp of spinal and epidural anesth during preg, unsp tri 20151001 22991231 O2960 Failed or difficult intubation for anesth dur preg, unsp tri 20151001 22991231 O2961 Fail or difficult intubation for anesth dur preg, first tri 20151001 22991231 O2962 Fail or difficult intubation for anesth dur preg, second tri 20151001 22991231 O2963 Fail or difficult intubation for anesth dur preg, third tri 20151001 22991231 O298X1 Oth comp of anesthesia during pregnancy, first trimester 20151001 22991231 O298X2 Oth comp of anesthesia during pregnancy, second trimester 20151001 22991231 O298X3 Oth comp of anesthesia during pregnancy, third trimester 20151001 22991231
63 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O298X9 Oth comp of anesthesia during pregnancy, unsp trimester 20151001 22991231 O2990 Unsp comp of anesthesia during pregnancy, unsp trimester 20151001 22991231 O2991 Unsp comp of anesthesia during pregnancy, first trimester 20151001 22991231 O2992 Unsp comp of anesthesia during pregnancy, second trimester 20151001 22991231 O2993 Unsp comp of anesthesia during pregnancy, third trimester 20151001 22991231 O30001 Twin preg, unsp num plcnta & amnio sacs, first trimester 20151001 22991231 O30002 Twin preg, unsp num plcnta & amnio sacs, second trimester 20151001 22991231 O30003 Twin preg, unsp num plcnta & amnio sacs, third trimester 20151001 22991231 O30009 Twin pregnancy, unsp num plcnta & amnio sacs, unsp trimester 20151001 22991231 O30011 Twin pregnancy, monochorionic/monoamniotic, first trimester 20151001 22991231 O30012 Twin pregnancy, monochorionic/monoamniotic, second trimester 20151001 22991231 O30013 Twin pregnancy, monochorionic/monoamniotic, third trimester 20151001 22991231 O30019 Twin pregnancy, monochorionic/monoamniotic, unsp trimester 20151001 22991231 O30031 Twin pregnancy, monochorionic/diamniotic, first trimester 20151001 22991231 O30032 Twin pregnancy, monochorionic/diamniotic, second trimester 20151001 22991231 O30033 Twin pregnancy, monochorionic/diamniotic, third trimester 20151001 22991231 O30039 Twin pregnancy, monochorionic/diamniotic, unsp trimester 20151001 22991231 O30041 Twin pregnancy, dichorionic/diamniotic, first trimester 20151001 22991231 O30042 Twin pregnancy, dichorionic/diamniotic, second trimester 20151001 22991231 O30043 Twin pregnancy, dichorionic/diamniotic, third trimester 20151001 22991231 O30049 Twin pregnancy, dichorionic/diamniotic, unsp trimester 20151001 22991231 O30091 Twin preg, unable to dtrm num plcnta & amnio sacs, first tri 20151001 22991231 O30092 Twin preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 20151001 22991231 O30093 Twin preg, unable to dtrm num plcnta & amnio sacs, third tri 20151001 22991231 O30099 Twin preg, unable to dtrm num plcnta & amnio sacs, unsp tri 20151001 22991231 O30101 Triplet preg, unsp num plcnta & amnio sacs, first trimester 20151001 22991231 O30102 Triplet preg, unsp num plcnta & amnio sacs, second trimester 20151001 22991231 O30103 Triplet preg, unsp num plcnta & amnio sacs, third trimester 20151001 22991231 O30109 Triplet preg, unsp num plcnta & amnio sacs, unsp trimester 20151001 22991231 O30111 Triplet preg w two or more monochorionic fetuses, first tri 20151001 22991231 O30112 Triplet preg w two or more monochorionic fetuses, second tri 20151001 22991231 O30113 Triplet preg w two or more monochorionic fetuses, third tri 20151001 22991231
64 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O30119 Triplet preg w two or more monochorionic fetuses, unsp tri 20151001 22991231 O30121 Triplet preg w two or more monoamnio fetuses, first tri 20151001 22991231 O30122 Triplet preg w two or more monoamnio fetuses, second tri 20151001 22991231 O30123 Triplet preg w two or more monoamnio fetuses, third tri 20151001 22991231 O30129 Triplet preg w two or more monoamnio fetuses, unsp trimester 20151001 22991231 O30131 Triplet pregnancy, trichorionic/triamniotic, first trimester 20181001 22991231 O30132 Triplet preg, trichorionic/triamniotic, second trimester 20181001 22991231 O30133 Triplet pregnancy, trichorionic/triamniotic, third trimester 20181001 22991231 O30139 Triplet pregnancy, trichorionic/triamniotic, unsp trimester 20181001 22991231 O30191 Trp preg, unable to dtrm num plcnta & amnio sacs, first tri 20151001 22991231 O30192 Trp preg, unable to dtrm num plcnta & amnio sacs, second tri 20151001 22991231 O30193 Trp preg, unable to dtrm num plcnta & amnio sacs, third tri 20151001 22991231 O30199 Trp preg, unable to dtrm num plcnta & amnio sacs, unsp tri 20151001 22991231 O30201 Quad preg, unsp num plcnta & amnio sacs, first trimester 20151001 22991231 O30202 Quad preg, unsp num plcnta & amnio sacs, second trimester 20151001 22991231 O30203 Quad preg, unsp num plcnta & amnio sacs, third trimester 20151001 22991231 O30209 Quad pregnancy, unsp num plcnta & amnio sacs, unsp trimester 20151001 22991231 O30211 Quad preg w two or more monochorionic fetuses, first tri 20151001 22991231 O30212 Quad preg w two or more monochorionic fetuses, second tri 20151001 22991231 O30213 Quad preg w two or more monochorionic fetuses, third tri 20151001 22991231 O30219 Quad preg w two or more monochorionic fetuses, unsp tri 20151001 22991231 O30221 Quad preg w two or more monoamnio fetuses, first trimester 20151001 22991231 O30222 Quad preg w two or more monoamnio fetuses, second trimester 20151001 22991231 O30223 Quad preg w two or more monoamnio fetuses, third trimester 20151001 22991231 O30229 Quad preg w two or more monoamnio fetuses, unsp trimester 20151001 22991231 O30231 Quad preg, quadrachorionic/quadra-amniotic, first trimester 20181001 22991231 O30232 Quad preg, quadrachorionic/quadra-amniotic, second trimester 20181001 22991231 O30233 Quad preg, quadrachorionic/quadra-amniotic, third trimester 20181001 22991231 O30239 Quad preg, quadrachorionic/quadra-amniotic, unsp trimester 20181001 22991231 O30291 Quad preg, unable to dtrm num plcnta & amnio sacs, first tri 20151001 22991231 O30292 Quad preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 20151001 22991231 O30293 Quad preg, unable to dtrm num plcnta & amnio sacs, third tri 20151001 22991231
65 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O30299 Quad preg, unable to dtrm num plcnta & amnio sacs, unsp tri 20151001 22991231 O30801 Oth multiple gest, unsp num plcnta & amnio sacs, first tri 20151001 22991231 O30802 Oth multiple gest, unsp num plcnta & amnio sacs, second tri 20151001 22991231 O30803 Oth multiple gest, unsp num plcnta & amnio sacs, third tri 20151001 22991231 O30809 Oth multiple gest, unsp num plcnta & amnio sacs, unsp tri 20151001 22991231 O30811 Oth mult gest w two or more monochorionic fetuses, first tri 20151001 22991231 O30812 Oth mult gest w two or more monochorionic fetuses, 2nd tri 20151001 22991231 O30813 Oth mult gest w two or more monochorionic fetuses, third tri 20151001 22991231 O30819 Oth mult gest w two or more monochorionic fetuses, unsp tri 20151001 22991231 O30821 Oth multiple gest w two or more monoamnio fetuses, first tri 20151001 22991231 O30822 Oth mult gest w two or more monoamnio fetuses, second tri 20151001 22991231 O30823 Oth multiple gest w two or more monoamnio fetuses, third tri 20151001 22991231 O30829 Oth multiple gest w two or more monoamnio fetuses, unsp tri 20151001 22991231 O30831 Oth mult gest, num chorions & amnions = num ftses, 1st tri 20181001 22991231 O30832 Oth mult gest, num chorions & amnions = num ftses, 2nd tri 20181001 22991231 O30833 Oth mult gest, num chorions & amnions = num ftses, 3rd tri 20181001 22991231 O30839 Oth mult gest, num chorions & amnions = num ftses, unsp tri 20181001 22991231 O30891 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 1st tri 20151001 22991231 O30892 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 2nd tri 20151001 22991231 O30893 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 3rd tri 20151001 22991231 O30899 Oth mult gest,unab to dtrm num plcnta & amnio sacs, unsp tri 20151001 22991231 O3090 Multiple gestation, unspecified, unspecified trimester 20151001 22991231 O3091 Multiple gestation, unspecified, first trimester 20151001 22991231 O3092 Multiple gestation, unspecified, second trimester 20151001 22991231 O3093 Multiple gestation, unspecified, third trimester 20151001 22991231 O3100X0 Papyraceous fetus, unsp trimester, not applicable or unsp 20151001 22991231 O3100X1 Papyraceous fetus, unspecified trimester, fetus 1 20151001 22991231 O3100X2 Papyraceous fetus, unspecified trimester, fetus 2 20151001 22991231 O3100X3 Papyraceous fetus, unspecified trimester, fetus 3 20151001 22991231 O3100X4 Papyraceous fetus, unspecified trimester, fetus 4 20151001 22991231 O3100X5 Papyraceous fetus, unspecified trimester, fetus 5 20151001 22991231 O3100X9 Papyraceous fetus, unspecified trimester, other fetus 20151001 22991231
66 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3101X0 Papyraceous fetus, first trimester, not applicable or unsp 20151001 22991231 O3101X1 Papyraceous fetus, first trimester, fetus 1 20151001 22991231 O3101X2 Papyraceous fetus, first trimester, fetus 2 20151001 22991231 O3101X3 Papyraceous fetus, first trimester, fetus 3 20151001 22991231 O3101X4 Papyraceous fetus, first trimester, fetus 4 20151001 22991231 O3101X5 Papyraceous fetus, first trimester, fetus 5 20151001 22991231 O3101X9 Papyraceous fetus, first trimester, other fetus 20151001 22991231 O3102X0 Papyraceous fetus, second trimester, not applicable or unsp 20151001 22991231 O3102X1 Papyraceous fetus, second trimester, fetus 1 20151001 22991231 O3102X2 Papyraceous fetus, second trimester, fetus 2 20151001 22991231 O3102X3 Papyraceous fetus, second trimester, fetus 3 20151001 22991231 O3102X4 Papyraceous fetus, second trimester, fetus 4 20151001 22991231 O3102X5 Papyraceous fetus, second trimester, fetus 5 20151001 22991231 O3102X9 Papyraceous fetus, second trimester, other fetus 20151001 22991231 O3103X0 Papyraceous fetus, third trimester, not applicable or unsp 20151001 22991231 O3103X1 Papyraceous fetus, third trimester, fetus 1 20151001 22991231 O3103X2 Papyraceous fetus, third trimester, fetus 2 20151001 22991231 O3103X3 Papyraceous fetus, third trimester, fetus 3 20151001 22991231 O3103X4 Papyraceous fetus, third trimester, fetus 4 20151001 22991231 O3103X5 Papyraceous fetus, third trimester, fetus 5 20151001 22991231 O3103X9 Papyraceous fetus, third trimester, other fetus 20151001 22991231 O3110X0 Cont preg aft spon abort of one fts or more, unsp tri, unsp 20151001 22991231 O3110X1 Cont preg aft spon abort of one fts or more, unsp tri, fts1 20151001 22991231 O3110X2 Cont preg aft spon abort of one fts or more, unsp tri, fts2 20151001 22991231 O3110X3 Cont preg aft spon abort of one fts or more, unsp tri, fts3 20151001 22991231 O3110X4 Cont preg aft spon abort of one fts or more, unsp tri, fts4 20151001 22991231 O3110X5 Cont preg aft spon abort of one fts or more, unsp tri, fts5 20151001 22991231 O3110X9 Cont preg aft spon abort of one fetus or more, unsp tri, oth 20151001 22991231 O3111X0 Cont preg aft spon abort of one fts or more, first tri, unsp 20151001 22991231 O3111X1 Cont preg aft spon abort of one fts or more, first tri, fts1 20151001 22991231 O3111X2 Cont preg aft spon abort of one fts or more, first tri, fts2 20151001 22991231 O3111X3 Cont preg aft spon abort of one fts or more, first tri, fts3 20151001 22991231
67 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3111X4 Cont preg aft spon abort of one fts or more, first tri, fts4 20151001 22991231 O3111X5 Cont preg aft spon abort of one fts or more, first tri, fts5 20151001 22991231 O3111X9 Cont preg aft spon abort of one fts or more, first tri, oth 20151001 22991231 O3112X0 Cont preg aft spon abort of one fetus or more, 2nd tri, unsp 20151001 22991231 O3112X1 Cont preg aft spon abort of one fetus or more, 2nd tri, fts1 20151001 22991231 O3112X2 Cont preg aft spon abort of one fetus or more, 2nd tri, fts2 20151001 22991231 O3112X3 Cont preg aft spon abort of one fetus or more, 2nd tri, fts3 20151001 22991231 O3112X4 Cont preg aft spon abort of one fetus or more, 2nd tri, fts4 20151001 22991231 O3112X5 Cont preg aft spon abort of one fetus or more, 2nd tri, fts5 20151001 22991231 O3112X9 Cont preg aft spon abort of one fetus or more, 2nd tri, oth 20151001 22991231 O3113X0 Cont preg aft spon abort of one fts or more, third tri, unsp 20151001 22991231 O3113X1 Cont preg aft spon abort of one fts or more, third tri, fts1 20151001 22991231 O3113X2 Cont preg aft spon abort of one fts or more, third tri, fts2 20151001 22991231 O3113X3 Cont preg aft spon abort of one fts or more, third tri, fts3 20151001 22991231 O3113X4 Cont preg aft spon abort of one fts or more, third tri, fts4 20151001 22991231 O3113X5 Cont preg aft spon abort of one fts or more, third tri, fts5 20151001 22991231 O3113X9 Cont preg aft spon abort of one fts or more, third tri, oth 20151001 22991231 O3120X0 Cont preg aft uterin dth of one fts or more, unsp tri, unsp 20151001 22991231 O3120X1 Cont preg aft uterin dth of one fts or more, unsp tri, fts1 20151001 22991231 O3120X2 Cont preg aft uterin dth of one fts or more, unsp tri, fts2 20151001 22991231 O3120X3 Cont preg aft uterin dth of one fts or more, unsp tri, fts3 20151001 22991231 O3120X4 Cont preg aft uterin dth of one fts or more, unsp tri, fts4 20151001 22991231 O3120X5 Cont preg aft uterin dth of one fts or more, unsp tri, fts5 20151001 22991231 O3120X9 Cont preg aft uterin dth of one fetus or more, unsp tri, oth 20151001 22991231 O3121X0 Cont preg aft uterin dth of one fts or more, first tri, unsp 20151001 22991231 O3121X1 Cont preg aft uterin dth of one fts or more, first tri, fts1 20151001 22991231 O3121X2 Cont preg aft uterin dth of one fts or more, first tri, fts2 20151001 22991231 O3121X3 Cont preg aft uterin dth of one fts or more, first tri, fts3 20151001 22991231 O3121X4 Cont preg aft uterin dth of one fts or more, first tri, fts4 20151001 22991231 O3121X5 Cont preg aft uterin dth of one fts or more, first tri, fts5 20151001 22991231 O3121X9 Cont preg aft uterin dth of one fts or more, first tri, oth 20151001 22991231 O3122X0 Cont preg aft uterin dth of one fetus or more, 2nd tri, unsp 20151001 22991231
68 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3122X1 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts1 20151001 22991231 O3122X2 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts2 20151001 22991231 O3122X3 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts3 20151001 22991231 O3122X4 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts4 20151001 22991231 O3122X5 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts5 20151001 22991231 O3122X9 Cont preg aft uterin dth of one fetus or more, 2nd tri, oth 20151001 22991231 O3123X0 Cont preg aft uterin dth of one fts or more, third tri, unsp 20151001 22991231 O3123X1 Cont preg aft uterin dth of one fts or more, third tri, fts1 20151001 22991231 O3123X2 Cont preg aft uterin dth of one fts or more, third tri, fts2 20151001 22991231 O3123X3 Cont preg aft uterin dth of one fts or more, third tri, fts3 20151001 22991231 O3123X4 Cont preg aft uterin dth of one fts or more, third tri, fts4 20151001 22991231 O3123X5 Cont preg aft uterin dth of one fts or more, third tri, fts5 20151001 22991231 O3123X9 Cont preg aft uterin dth of one fts or more, third tri, oth 20151001 22991231 O3130X0 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,unsp 20151001 22991231 O3130X1 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,fts1 20151001 22991231 O3130X2 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,fts2 20151001 22991231 O3130X3 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,fts3 20151001 22991231 O3130X4 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,fts4 20151001 22991231 O3130X5 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri,fts5 20151001 22991231 O3130X9 Cont preg aft elctv fetl rdct of 1 fts or more,unsp tri, oth 20151001 22991231 O3131X0 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, unsp 20151001 22991231 O3131X1 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts1 20151001 22991231 O3131X2 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts2 20151001 22991231 O3131X3 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts3 20151001 22991231 O3131X4 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts4 20151001 22991231 O3131X5 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts5 20151001 22991231 O3131X9 Cont preg aft elctv fetl rdct of 1 fts or more, 1st tri, oth 20151001 22991231 O3132X0 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, unsp 20151001 22991231 O3132X1 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts1 20151001 22991231 O3132X2 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts2 20151001 22991231 O3132X3 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts3 20151001 22991231 O3132X4 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts4 20151001 22991231
69 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3132X5 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts5 20151001 22991231 O3132X9 Cont preg aft elctv fetl rdct of 1 fts or more, 2nd tri, oth 20151001 22991231 O3133X0 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, unsp 20151001 22991231 O3133X1 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts1 20151001 22991231 O3133X2 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts2 20151001 22991231 O3133X3 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts3 20151001 22991231 O3133X4 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts4 20151001 22991231 O3133X5 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts5 20151001 22991231 O3133X9 Cont preg aft elctv fetl rdct of 1 fts or more, 3rd tri, oth 20151001 22991231 O318X10 Oth comp specific to multiple gest, first trimester, unsp 20151001 22991231 O318X11 Oth comp specific to multiple gest, first trimester, fetus 1 20151001 22991231 O318X12 Oth comp specific to multiple gest, first trimester, fetus 2 20151001 22991231 O318X13 Oth comp specific to multiple gest, first trimester, fetus 3 20151001 22991231 O318X14 Oth comp specific to multiple gest, first trimester, fetus 4 20151001 22991231 O318X15 Oth comp specific to multiple gest, first trimester, fetus 5 20151001 22991231 O318X19 Oth comp specific to multiple gest, first trimester, oth 20151001 22991231 O318X20 Oth comp specific to multiple gest, second trimester, unsp 20151001 22991231 O318X21 Oth comp specific to multiple gest, second tri, fetus 1 20151001 22991231 O318X22 Oth comp specific to multiple gest, second tri, fetus 2 20151001 22991231 O318X23 Oth comp specific to multiple gest, second tri, fetus 3 20151001 22991231 O318X24 Oth comp specific to multiple gest, second tri, fetus 4 20151001 22991231 O318X25 Oth comp specific to multiple gest, second tri, fetus 5 20151001 22991231 O318X29 Oth comp specific to multiple gest, second trimester, oth 20151001 22991231 O318X30 Oth comp specific to multiple gest, third trimester, unsp 20151001 22991231 O318X31 Oth comp specific to multiple gest, third trimester, fetus 1 20151001 22991231 O318X32 Oth comp specific to multiple gest, third trimester, fetus 2 20151001 22991231 O318X33 Oth comp specific to multiple gest, third trimester, fetus 3 20151001 22991231 O318X34 Oth comp specific to multiple gest, third trimester, fetus 4 20151001 22991231 O318X35 Oth comp specific to multiple gest, third trimester, fetus 5 20151001 22991231 O318X39 Oth comp specific to multiple gest, third trimester, oth 20151001 22991231 O318X90 Oth comp specific to multiple gest, unsp trimester, unsp 20151001 22991231 O318X91 Oth comp specific to multiple gest, unsp trimester, fetus 1 20151001 22991231
70 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O318X92 Oth comp specific to multiple gest, unsp trimester, fetus 2 20151001 22991231 O318X93 Oth comp specific to multiple gest, unsp trimester, fetus 3 20151001 22991231 O318X94 Oth comp specific to multiple gest, unsp trimester, fetus 4 20151001 22991231 O318X95 Oth comp specific to multiple gest, unsp trimester, fetus 5 20151001 22991231 O318X99 Oth comp specific to multiple gestation, unsp trimester, oth 20151001 22991231 O320XX0 Maternal care for unstable lie, not applicable or unsp 20151001 22991231 O320XX1 Maternal care for unstable lie, fetus 1 20151001 22991231 O320XX2 Maternal care for unstable lie, fetus 2 20151001 22991231 O320XX3 Maternal care for unstable lie, fetus 3 20151001 22991231 O320XX4 Maternal care for unstable lie, fetus 4 20151001 22991231 O320XX5 Maternal care for unstable lie, fetus 5 20151001 22991231 O320XX9 Maternal care for unstable lie, other fetus 20151001 22991231 O321XX0 Maternal care for breech presentation, unsp 20151001 22991231 O321XX1 Maternal care for breech presentation, fetus 1 20151001 22991231 O321XX2 Maternal care for breech presentation, fetus 2 20151001 22991231 O321XX3 Maternal care for breech presentation, fetus 3 20151001 22991231 O321XX4 Maternal care for breech presentation, fetus 4 20151001 22991231 O321XX5 Maternal care for breech presentation, fetus 5 20151001 22991231 O321XX9 Maternal care for breech presentation, other fetus 20151001 22991231 O322XX0 Maternal care for transverse and oblique lie, unsp 20151001 22991231 O322XX1 Maternal care for transverse and oblique lie, fetus 1 20151001 22991231 O322XX2 Maternal care for transverse and oblique lie, fetus 2 20151001 22991231 O322XX3 Maternal care for transverse and oblique lie, fetus 3 20151001 22991231 O322XX4 Maternal care for transverse and oblique lie, fetus 4 20151001 22991231 O322XX5 Maternal care for transverse and oblique lie, fetus 5 20151001 22991231 O322XX9 Maternal care for transverse and oblique lie, other fetus 20151001 22991231 O323XX0 Maternal care for face, brow and chin presentation, unsp 20151001 22991231 O323XX1 Maternal care for face, brow and chin presentation, fetus 1 20151001 22991231 O323XX2 Maternal care for face, brow and chin presentation, fetus 2 20151001 22991231 O323XX3 Maternal care for face, brow and chin presentation, fetus 3 20151001 22991231 O323XX4 Maternal care for face, brow and chin presentation, fetus 4 20151001 22991231 O323XX5 Maternal care for face, brow and chin presentation, fetus 5 20151001 22991231
71 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O323XX9 Maternal care for face, brow and chin presentation, oth 20151001 22991231 O324XX0 Maternal care for high head at term, not applicable or unsp 20151001 22991231 O324XX1 Maternal care for high head at term, fetus 1 20151001 22991231 O324XX2 Maternal care for high head at term, fetus 2 20151001 22991231 O324XX3 Maternal care for high head at term, fetus 3 20151001 22991231 O324XX4 Maternal care for high head at term, fetus 4 20151001 22991231 O324XX5 Maternal care for high head at term, fetus 5 20151001 22991231 O324XX9 Maternal care for high head at term, other fetus 20151001 22991231 O326XX0 Maternal care for compound presentation, unsp 20151001 22991231 O326XX1 Maternal care for compound presentation, fetus 1 20151001 22991231 O326XX2 Maternal care for compound presentation, fetus 2 20151001 22991231 O326XX3 Maternal care for compound presentation, fetus 3 20151001 22991231 O326XX4 Maternal care for compound presentation, fetus 4 20151001 22991231 O326XX5 Maternal care for compound presentation, fetus 5 20151001 22991231 O326XX9 Maternal care for compound presentation, other fetus 20151001 22991231 O328XX0 Maternal care for oth malpresentation of fetus, unsp 20151001 22991231 O328XX1 Maternal care for other malpresentation of fetus, fetus 1 20151001 22991231 O328XX2 Maternal care for other malpresentation of fetus, fetus 2 20151001 22991231 O328XX3 Maternal care for other malpresentation of fetus, fetus 3 20151001 22991231 O328XX4 Maternal care for other malpresentation of fetus, fetus 4 20151001 22991231 O328XX5 Maternal care for other malpresentation of fetus, fetus 5 20151001 22991231 O328XX9 Maternal care for oth malpresentation of fetus, other fetus 20151001 22991231 O329XX0 Maternal care for malpresentation of fetus, unsp, unsp 20151001 22991231 O329XX1 Maternal care for malpresentation of fetus, unsp, fetus 1 20151001 22991231 O329XX2 Maternal care for malpresentation of fetus, unsp, fetus 2 20151001 22991231 O329XX3 Maternal care for malpresentation of fetus, unsp, fetus 3 20151001 22991231 O329XX4 Maternal care for malpresentation of fetus, unsp, fetus 4 20151001 22991231 O329XX5 Maternal care for malpresentation of fetus, unsp, fetus 5 20151001 22991231 O329XX9 Maternal care for malpresentation of fetus, unsp, oth fetus 20151001 22991231 O330 Matern care for disproprtn d/t deformity of matern pelv bone 20151001 22991231 O331 Matern care for disproprtn d/t generally contracted pelvis 20151001 22991231 O332 Maternal care for disproprtn due to inlet contrctn of pelvis 20151001 22991231
72 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O333XX0 Matern care for disproprtn d/t outlet contrctn of pelv, unsp 20151001 22991231 O333XX1 Matern care for disproprtn d/t outlet contrctn of pelv, fts1 20151001 22991231 O333XX2 Matern care for disproprtn d/t outlet contrctn of pelv, fts2 20151001 22991231 O333XX3 Matern care for disproprtn d/t outlet contrctn of pelv, fts3 20151001 22991231 O333XX4 Matern care for disproprtn d/t outlet contrctn of pelv, fts4 20151001 22991231 O333XX5 Matern care for disproprtn d/t outlet contrctn of pelv, fts5 20151001 22991231 O333XX9 Matern care for disproprtn d/t outlet contrctn of pelv, oth 20151001 22991231 O334XX0 Matern care for disproprtn of mix matern & fetl origin, unsp 20151001 22991231 O334XX1 Matern care for disproprtn of mix matern & fetl origin, fts1 20151001 22991231 O334XX2 Matern care for disproprtn of mix matern & fetl origin, fts2 20151001 22991231 O334XX3 Matern care for disproprtn of mix matern & fetl origin, fts3 20151001 22991231 O334XX4 Matern care for disproprtn of mix matern & fetl origin, fts4 20151001 22991231 O334XX5 Matern care for disproprtn of mix matern & fetl origin, fts5 20151001 22991231 O334XX9 Matern care for disproprtn of mix matern & fetl origin, oth 20151001 22991231 O335XX0 Matern care for disproprtn d/t unusually large fetus, unsp 20151001 22991231 O335XX1 Matern care for disproprtn d/t unusually large fetus, fts1 20151001 22991231 O335XX2 Matern care for disproprtn d/t unusually large fetus, fts2 20151001 22991231 O335XX3 Matern care for disproprtn d/t unusually large fetus, fts3 20151001 22991231 O335XX4 Matern care for disproprtn d/t unusually large fetus, fts4 20151001 22991231 O335XX5 Matern care for disproprtn d/t unusually large fetus, fts5 20151001 22991231 O335XX9 Matern care for disproprtn due to unusually large fetus, oth 20151001 22991231 O336XX0 Matern care for disproprtn due to hydrocephalic fetus, unsp 20151001 22991231 O336XX1 Matern care for disproprtn due to hydrocephalic fetus, fts1 20151001 22991231 O336XX2 Matern care for disproprtn due to hydrocephalic fetus, fts2 20151001 22991231 O336XX3 Matern care for disproprtn due to hydrocephalic fetus, fts3 20151001 22991231 O336XX4 Matern care for disproprtn due to hydrocephalic fetus, fts4 20151001 22991231 O336XX5 Matern care for disproprtn due to hydrocephalic fetus, fts5 20151001 22991231 O336XX9 Maternal care for disproprtn due to hydrocephalic fetus, oth 20151001 22991231 O337 Maternal care for disproportion due to oth fetal deformities 20151001 20160930 O337XX0 Maternal care for disproprtn due to other fetal deform, unsp 20161001 22991231 O337XX1 Matern care for disproprtn due to other fetal deform, fts1 20161001 22991231 O337XX2 Matern care for disproprtn due to other fetal deform, fts2 20161001 22991231
73 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O337XX3 Matern care for disproprtn due to other fetal deform, fts3 20161001 22991231 O337XX4 Matern care for disproprtn due to other fetal deform, fts4 20161001 22991231 O337XX5 Matern care for disproprtn due to other fetal deform, fts5 20161001 22991231 O337XX9 Maternal care for disproprtn due to other fetal deform, oth 20161001 22991231 O338 Maternal care for disproportion of other origin 20151001 22991231 O339 Maternal care for disproportion, unspecified 20151001 22991231 O3400 Maternal care for unsp congen malform of uterus, unsp tri 20151001 22991231 O3401 Maternal care for unsp congen malform of uterus, first tri 20151001 22991231 O3402 Maternal care for unsp congen malform of uterus, second tri 20151001 22991231 O3403 Maternal care for unsp congen malform of uterus, third tri 20151001 22991231 O3410 Maternal care for benign tumor of corpus uteri, unsp tri 20151001 22991231 O3411 Maternal care for benign tumor of corpus uteri, first tri 20151001 22991231 O3412 Maternal care for benign tumor of corpus uteri, second tri 20151001 22991231 O3413 Maternal care for benign tumor of corpus uteri, third tri 20151001 22991231 O3421 Maternal care for scar from previous cesarean delivery 20151001 20160930 O34211 Matern care for low transverse scar from prev cesarean del 20161001 22991231 O34212 Maternal care for vertical scar from previous cesarean del 20161001 22991231 O34219 Maternal care for unsp type scar from previous cesarean del 20161001 22991231 O3429 Maternal care due to uterine scar from oth previous surgery 20151001 22991231 O3430 Maternal care for cervical incompetence, unsp trimester 20151001 22991231 O3431 Maternal care for cervical incompetence, first trimester 20151001 22991231 O3432 Maternal care for cervical incompetence, second trimester 20151001 22991231 O3433 Maternal care for cervical incompetence, third trimester 20151001 22991231 O3440 Maternal care for oth abnlt of cervix, unsp trimester 20151001 22991231 O3441 Maternal care for oth abnlt of cervix, first trimester 20151001 22991231 O3442 Maternal care for oth abnlt of cervix, second trimester 20151001 22991231 O3443 Maternal care for oth abnlt of cervix, third trimester 20151001 22991231 O34511 Maternal care for incarceration of gravid uterus, first tri 20151001 22991231 O34512 Maternal care for incarceration of gravid uterus, second tri 20151001 22991231 O34513 Maternal care for incarceration of gravid uterus, third tri 20151001 22991231 O34519 Maternal care for incarceration of gravid uterus, unsp tri 20151001 22991231 O34521 Maternal care for prolapse of gravid uterus, first trimester 20151001 22991231
74 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O34522 Maternal care for prolapse of gravid uterus, second tri 20151001 22991231 O34523 Maternal care for prolapse of gravid uterus, third trimester 20151001 22991231 O34529 Maternal care for prolapse of gravid uterus, unsp trimester 20151001 22991231 O34531 Maternal care for retroversion of gravid uterus, first tri 20151001 22991231 O34532 Maternal care for retroversion of gravid uterus, second tri 20151001 22991231 O34533 Maternal care for retroversion of gravid uterus, third tri 20151001 22991231 O34539 Maternal care for retroversion of gravid uterus, unsp tri 20151001 22991231 O34591 Maternal care for oth abnlt of gravid uterus, first tri 20151001 22991231 O34592 Maternal care for oth abnlt of gravid uterus, second tri 20151001 22991231 O34593 Maternal care for oth abnlt of gravid uterus, third tri 20151001 22991231 O34599 Maternal care for oth abnlt of gravid uterus, unsp trimester 20151001 22991231 O3460 Maternal care for abnormality of vagina, unsp trimester 20151001 22991231 O3461 Maternal care for abnormality of vagina, first trimester 20151001 22991231 O3462 Maternal care for abnormality of vagina, second trimester 20151001 22991231 O3463 Maternal care for abnormality of vagina, third trimester 20151001 22991231 O3470 Maternal care for abnlt of vulva and perineum, unsp tri 20151001 22991231 O3471 Maternal care for abnlt of vulva and perineum, first tri 20151001 22991231 O3472 Maternal care for abnlt of vulva and perineum, second tri 20151001 22991231 O3473 Maternal care for abnlt of vulva and perineum, third tri 20151001 22991231 O3480 Maternal care for oth abnlt of pelvic organs, unsp trimester 20151001 22991231 O3481 Maternal care for oth abnlt of pelvic organs, first tri 20151001 22991231 O3482 Maternal care for oth abnlt of pelvic organs, second tri 20151001 22991231 O3483 Maternal care for oth abnlt of pelvic organs, third tri 20151001 22991231 O3490 Maternal care for abnlt of pelvic organ, unsp, unsp tri 20151001 22991231 O3491 Maternal care for abnlt of pelvic organ, unsp, first tri 20151001 22991231 O3492 Maternal care for abnlt of pelvic organ, unsp, second tri 20151001 22991231 O3493 Maternal care for abnlt of pelvic organ, unsp, third tri 20151001 22991231 O350XX0 Maternal care for (suspected) cnsl malform in fetus, unsp 20151001 22991231 O350XX1 Maternal care for (suspected) cnsl malform in fetus, fetus 1 20151001 22991231 O350XX2 Maternal care for (suspected) cnsl malform in fetus, fetus 2 20151001 22991231 O350XX3 Maternal care for (suspected) cnsl malform in fetus, fetus 3 20151001 22991231 O350XX4 Maternal care for (suspected) cnsl malform in fetus, fetus 4 20151001 22991231
75 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O350XX5 Maternal care for (suspected) cnsl malform in fetus, fetus 5 20151001 22991231 O350XX9 Maternal care for (suspected) cnsl malform in fetus, oth 20151001 22991231 O351XX0 Maternal care for chromosomal abnormality in fetus, unsp 20151001 22991231 O351XX1 Maternal care for chromosomal abnormality in fetus, fetus 1 20151001 22991231 O351XX2 Maternal care for chromosomal abnormality in fetus, fetus 2 20151001 22991231 O351XX3 Maternal care for chromosomal abnormality in fetus, fetus 3 20151001 22991231 O351XX4 Maternal care for chromosomal abnormality in fetus, fetus 4 20151001 22991231 O351XX5 Maternal care for chromosomal abnormality in fetus, fetus 5 20151001 22991231 O351XX9 Maternal care for chromosomal abnormality in fetus, oth 20151001 22991231 O352XX0 Maternal care for hereditary disease in fetus, unsp 20151001 22991231 O352XX1 Maternal care for hereditary disease in fetus, fetus 1 20151001 22991231 O352XX2 Maternal care for hereditary disease in fetus, fetus 2 20151001 22991231 O352XX3 Maternal care for hereditary disease in fetus, fetus 3 20151001 22991231 O352XX4 Maternal care for hereditary disease in fetus, fetus 4 20151001 22991231 O352XX5 Maternal care for hereditary disease in fetus, fetus 5 20151001 22991231 O352XX9 Maternal care for hereditary disease in fetus, oth 20151001 22991231 O353XX0 Matern care for damag to fts from viral dis in mother, unsp 20151001 22991231 O353XX1 Matern care for damag to fts from viral dis in mother, fts1 20151001 22991231 O353XX2 Matern care for damag to fts from viral dis in mother, fts2 20151001 22991231 O353XX3 Matern care for damag to fts from viral dis in mother, fts3 20151001 22991231 O353XX4 Matern care for damag to fts from viral dis in mother, fts4 20151001 22991231 O353XX5 Matern care for damag to fts from viral dis in mother, fts5 20151001 22991231 O353XX9 Matern care for damag to fetus from viral dis in mother, oth 20151001 22991231 O354XX0 Maternal care for damage to fetus from alcohol, unsp 20151001 22991231 O354XX1 Maternal care for damage to fetus from alcohol, fetus 1 20151001 22991231 O354XX2 Maternal care for damage to fetus from alcohol, fetus 2 20151001 22991231 O354XX3 Maternal care for damage to fetus from alcohol, fetus 3 20151001 22991231 O354XX4 Maternal care for damage to fetus from alcohol, fetus 4 20151001 22991231 O354XX5 Maternal care for damage to fetus from alcohol, fetus 5 20151001 22991231 O354XX9 Maternal care for damage to fetus from alcohol, oth 20151001 22991231 O355XX0 Maternal care for (suspected) damage to fetus by drugs, unsp 20151001 22991231 O355XX1 Maternal care for damage to fetus by drugs, fetus 1 20151001 22991231
76 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O355XX2 Maternal care for damage to fetus by drugs, fetus 2 20151001 22991231 O355XX3 Maternal care for damage to fetus by drugs, fetus 3 20151001 22991231 O355XX4 Maternal care for damage to fetus by drugs, fetus 4 20151001 22991231 O355XX5 Maternal care for damage to fetus by drugs, fetus 5 20151001 22991231 O355XX9 Maternal care for (suspected) damage to fetus by drugs, oth 20151001 22991231 O356XX0 Maternal care for damage to fetus by radiation, unsp 20151001 22991231 O356XX1 Maternal care for damage to fetus by radiation, fetus 1 20151001 22991231 O356XX2 Maternal care for damage to fetus by radiation, fetus 2 20151001 22991231 O356XX3 Maternal care for damage to fetus by radiation, fetus 3 20151001 22991231 O356XX4 Maternal care for damage to fetus by radiation, fetus 4 20151001 22991231 O356XX5 Maternal care for damage to fetus by radiation, fetus 5 20151001 22991231 O356XX9 Maternal care for damage to fetus by radiation, oth 20151001 22991231 O358XX0 Maternal care for oth fetal abnormality and damage, unsp 20151001 22991231 O358XX1 Maternal care for oth fetal abnormality and damage, fetus 1 20151001 22991231 O358XX2 Maternal care for oth fetal abnormality and damage, fetus 2 20151001 22991231 O358XX3 Maternal care for oth fetal abnormality and damage, fetus 3 20151001 22991231 O358XX4 Maternal care for oth fetal abnormality and damage, fetus 4 20151001 22991231 O358XX5 Maternal care for oth fetal abnormality and damage, fetus 5 20151001 22991231 O358XX9 Maternal care for oth fetal abnormality and damage, oth 20151001 22991231 O359XX0 Maternal care for fetal abnormality and damage, unsp, unsp 20151001 22991231 O359XX1 Maternal care for fetal abnlt and damage, unsp, fetus 1 20151001 22991231 O359XX2 Maternal care for fetal abnlt and damage, unsp, fetus 2 20151001 22991231 O359XX3 Maternal care for fetal abnlt and damage, unsp, fetus 3 20151001 22991231 O359XX4 Maternal care for fetal abnlt and damage, unsp, fetus 4 20151001 22991231 O359XX5 Maternal care for fetal abnlt and damage, unsp, fetus 5 20151001 22991231 O359XX9 Maternal care for fetal abnormality and damage, unsp, oth 20151001 22991231 O360110 Maternal care for anti-D antibodies, first trimester, unsp 20151001 22991231 O360111 Maternal care for anti-D antibodies, first tri, fetus 1 20151001 22991231 O360112 Maternal care for anti-D antibodies, first tri, fetus 2 20151001 22991231 O360113 Maternal care for anti-D antibodies, first tri, fetus 3 20151001 22991231 O360114 Maternal care for anti-D antibodies, first tri, fetus 4 20151001 22991231 O360115 Maternal care for anti-D antibodies, first tri, fetus 5 20151001 22991231
77 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O360119 Maternal care for anti-D antibodies, first trimester, oth 20151001 22991231 O360120 Maternal care for anti-D antibodies, second trimester, unsp 20151001 22991231 O360121 Maternal care for anti-D antibodies, second tri, fetus 1 20151001 22991231 O360122 Maternal care for anti-D antibodies, second tri, fetus 2 20151001 22991231 O360123 Maternal care for anti-D antibodies, second tri, fetus 3 20151001 22991231 O360124 Maternal care for anti-D antibodies, second tri, fetus 4 20151001 22991231 O360125 Maternal care for anti-D antibodies, second tri, fetus 5 20151001 22991231 O360129 Maternal care for anti-D antibodies, second trimester, oth 20151001 22991231 O360130 Maternal care for anti-D antibodies, third trimester, unsp 20151001 22991231 O360131 Maternal care for anti-D antibodies, third tri, fetus 1 20151001 22991231 O360132 Maternal care for anti-D antibodies, third tri, fetus 2 20151001 22991231 O360133 Maternal care for anti-D antibodies, third tri, fetus 3 20151001 22991231 O360134 Maternal care for anti-D antibodies, third tri, fetus 4 20151001 22991231 O360135 Maternal care for anti-D antibodies, third tri, fetus 5 20151001 22991231 O360139 Maternal care for anti-D antibodies, third trimester, oth 20151001 22991231 O360190 Maternal care for anti-D antibodies, unsp trimester, unsp 20151001 22991231 O360191 Maternal care for anti-D antibodies, unsp trimester, fetus 1 20151001 22991231 O360192 Maternal care for anti-D antibodies, unsp trimester, fetus 2 20151001 22991231 O360193 Maternal care for anti-D antibodies, unsp trimester, fetus 3 20151001 22991231 O360194 Maternal care for anti-D antibodies, unsp trimester, fetus 4 20151001 22991231 O360195 Maternal care for anti-D antibodies, unsp trimester, fetus 5 20151001 22991231 O360199 Maternal care for anti-D antibodies, unsp trimester, oth 20151001 22991231 O360910 Maternal care for oth rhesus isoimmun, first trimester, unsp 20151001 22991231 O360911 Maternal care for oth rhesus isoimmun, first tri, fetus 1 20151001 22991231 O360912 Maternal care for oth rhesus isoimmun, first tri, fetus 2 20151001 22991231 O360913 Maternal care for oth rhesus isoimmun, first tri, fetus 3 20151001 22991231 O360914 Maternal care for oth rhesus isoimmun, first tri, fetus 4 20151001 22991231 O360915 Maternal care for oth rhesus isoimmun, first tri, fetus 5 20151001 22991231 O360919 Maternal care for oth rhesus isoimmun, first trimester, oth 20151001 22991231 O360920 Maternal care for oth rhesus isoimmun, second tri, unsp 20151001 22991231 O360921 Maternal care for oth rhesus isoimmun, second tri, fetus 1 20151001 22991231 O360922 Maternal care for oth rhesus isoimmun, second tri, fetus 2 20151001 22991231
78 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O360923 Maternal care for oth rhesus isoimmun, second tri, fetus 3 20151001 22991231 O360924 Maternal care for oth rhesus isoimmun, second tri, fetus 4 20151001 22991231 O360925 Maternal care for oth rhesus isoimmun, second tri, fetus 5 20151001 22991231 O360929 Maternal care for oth rhesus isoimmun, second trimester, oth 20151001 22991231 O360930 Maternal care for oth rhesus isoimmun, third trimester, unsp 20151001 22991231 O360931 Maternal care for oth rhesus isoimmun, third tri, fetus 1 20151001 22991231 O360932 Maternal care for oth rhesus isoimmun, third tri, fetus 2 20151001 22991231 O360933 Maternal care for oth rhesus isoimmun, third tri, fetus 3 20151001 22991231 O360934 Maternal care for oth rhesus isoimmun, third tri, fetus 4 20151001 22991231 O360935 Maternal care for oth rhesus isoimmun, third tri, fetus 5 20151001 22991231 O360939 Maternal care for oth rhesus isoimmun, third trimester, oth 20151001 22991231 O360990 Maternal care for oth rhesus isoimmun, unsp trimester, unsp 20151001 22991231 O360991 Maternal care for oth rhesus isoimmun, unsp tri, fetus 1 20151001 22991231 O360992 Maternal care for oth rhesus isoimmun, unsp tri, fetus 2 20151001 22991231 O360993 Maternal care for oth rhesus isoimmun, unsp tri, fetus 3 20151001 22991231 O360994 Maternal care for oth rhesus isoimmun, unsp tri, fetus 4 20151001 22991231 O360995 Maternal care for oth rhesus isoimmun, unsp tri, fetus 5 20151001 22991231 O360999 Maternal care for oth rhesus isoimmun, unsp trimester, oth 20151001 22991231 O361110 Maternal care for Anti-A sensitization, first tri, unsp 20151001 22991231 O361111 Maternal care for Anti-A sensitization, first tri, fetus 1 20151001 22991231 O361112 Maternal care for Anti-A sensitization, first tri, fetus 2 20151001 22991231 O361113 Maternal care for Anti-A sensitization, first tri, fetus 3 20151001 22991231 O361114 Maternal care for Anti-A sensitization, first tri, fetus 4 20151001 22991231 O361115 Maternal care for Anti-A sensitization, first tri, fetus 5 20151001 22991231 O361119 Maternal care for Anti-A sensitization, first trimester, oth 20151001 22991231 O361120 Maternal care for Anti-A sensitization, second tri, unsp 20151001 22991231 O361121 Maternal care for Anti-A sensitization, second tri, fetus 1 20151001 22991231 O361122 Maternal care for Anti-A sensitization, second tri, fetus 2 20151001 22991231 O361123 Maternal care for Anti-A sensitization, second tri, fetus 3 20151001 22991231 O361124 Maternal care for Anti-A sensitization, second tri, fetus 4 20151001 22991231 O361125 Maternal care for Anti-A sensitization, second tri, fetus 5 20151001 22991231 O361129 Maternal care for Anti-A sensitization, second tri, oth 20151001 22991231
79 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O361130 Maternal care for Anti-A sensitization, third tri, unsp 20151001 22991231 O361131 Maternal care for Anti-A sensitization, third tri, fetus 1 20151001 22991231 O361132 Maternal care for Anti-A sensitization, third tri, fetus 2 20151001 22991231 O361133 Maternal care for Anti-A sensitization, third tri, fetus 3 20151001 22991231 O361134 Maternal care for Anti-A sensitization, third tri, fetus 4 20151001 22991231 O361135 Maternal care for Anti-A sensitization, third tri, fetus 5 20151001 22991231 O361139 Maternal care for Anti-A sensitization, third trimester, oth 20151001 22991231 O361190 Maternal care for Anti-A sensitization, unsp trimester, unsp 20151001 22991231 O361191 Maternal care for Anti-A sensitization, unsp tri, fetus 1 20151001 22991231 O361192 Maternal care for Anti-A sensitization, unsp tri, fetus 2 20151001 22991231 O361193 Maternal care for Anti-A sensitization, unsp tri, fetus 3 20151001 22991231 O361194 Maternal care for Anti-A sensitization, unsp tri, fetus 4 20151001 22991231 O361195 Maternal care for Anti-A sensitization, unsp tri, fetus 5 20151001 22991231 O361199 Maternal care for Anti-A sensitization, unsp trimester, oth 20151001 22991231 O361910 Maternal care for oth isoimmunization, first trimester, unsp 20151001 22991231 O361911 Maternal care for oth isoimmun, first trimester, fetus 1 20151001 22991231 O361912 Maternal care for oth isoimmun, first trimester, fetus 2 20151001 22991231 O361913 Maternal care for oth isoimmun, first trimester, fetus 3 20151001 22991231 O361914 Maternal care for oth isoimmun, first trimester, fetus 4 20151001 22991231 O361915 Maternal care for oth isoimmun, first trimester, fetus 5 20151001 22991231 O361919 Maternal care for oth isoimmunization, first trimester, oth 20151001 22991231 O361920 Maternal care for oth isoimmun, second trimester, unsp 20151001 22991231 O361921 Maternal care for oth isoimmun, second trimester, fetus 1 20151001 22991231 O361922 Maternal care for oth isoimmun, second trimester, fetus 2 20151001 22991231 O361923 Maternal care for oth isoimmun, second trimester, fetus 3 20151001 22991231 O361924 Maternal care for oth isoimmun, second trimester, fetus 4 20151001 22991231 O361925 Maternal care for oth isoimmun, second trimester, fetus 5 20151001 22991231 O361929 Maternal care for oth isoimmunization, second trimester, oth 20151001 22991231 O361930 Maternal care for oth isoimmunization, third trimester, unsp 20151001 22991231 O361931 Maternal care for oth isoimmun, third trimester, fetus 1 20151001 22991231 O361932 Maternal care for oth isoimmun, third trimester, fetus 2 20151001 22991231 O361933 Maternal care for oth isoimmun, third trimester, fetus 3 20151001 22991231
80 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O361934 Maternal care for oth isoimmun, third trimester, fetus 4 20151001 22991231 O361935 Maternal care for oth isoimmun, third trimester, fetus 5 20151001 22991231 O361939 Maternal care for oth isoimmunization, third trimester, oth 20151001 22991231 O361990 Maternal care for oth isoimmunization, unsp trimester, unsp 20151001 22991231 O361991 Maternal care for oth isoimmun, unsp trimester, fetus 1 20151001 22991231 O361992 Maternal care for oth isoimmun, unsp trimester, fetus 2 20151001 22991231 O361993 Maternal care for oth isoimmun, unsp trimester, fetus 3 20151001 22991231 O361994 Maternal care for oth isoimmun, unsp trimester, fetus 4 20151001 22991231 O361995 Maternal care for oth isoimmun, unsp trimester, fetus 5 20151001 22991231 O361999 Maternal care for oth isoimmunization, unsp trimester, oth 20151001 22991231 O3620X0 Maternal care for hydrops fetalis, unsp trimester, unsp 20151001 22991231 O3620X1 Maternal care for hydrops fetalis, unsp trimester, fetus 1 20151001 22991231 O3620X2 Maternal care for hydrops fetalis, unsp trimester, fetus 2 20151001 22991231 O3620X3 Maternal care for hydrops fetalis, unsp trimester, fetus 3 20151001 22991231 O3620X4 Maternal care for hydrops fetalis, unsp trimester, fetus 4 20151001 22991231 O3620X5 Maternal care for hydrops fetalis, unsp trimester, fetus 5 20151001 22991231 O3620X9 Maternal care for hydrops fetalis, unsp trimester, oth fetus 20151001 22991231 O3621X0 Maternal care for hydrops fetalis, first trimester, unsp 20151001 22991231 O3621X1 Maternal care for hydrops fetalis, first trimester, fetus 1 20151001 22991231 O3621X2 Maternal care for hydrops fetalis, first trimester, fetus 2 20151001 22991231 O3621X3 Maternal care for hydrops fetalis, first trimester, fetus 3 20151001 22991231 O3621X4 Maternal care for hydrops fetalis, first trimester, fetus 4 20151001 22991231 O3621X5 Maternal care for hydrops fetalis, first trimester, fetus 5 20151001 22991231 O3621X9 Maternal care for hydrops fetalis, first trimester, oth 20151001 22991231 O3622X0 Maternal care for hydrops fetalis, second trimester, unsp 20151001 22991231 O3622X1 Maternal care for hydrops fetalis, second trimester, fetus 1 20151001 22991231 O3622X2 Maternal care for hydrops fetalis, second trimester, fetus 2 20151001 22991231 O3622X3 Maternal care for hydrops fetalis, second trimester, fetus 3 20151001 22991231 O3622X4 Maternal care for hydrops fetalis, second trimester, fetus 4 20151001 22991231 O3622X5 Maternal care for hydrops fetalis, second trimester, fetus 5 20151001 22991231 O3622X9 Maternal care for hydrops fetalis, second trimester, oth 20151001 22991231 O3623X0 Maternal care for hydrops fetalis, third trimester, unsp 20151001 22991231
81 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3623X1 Maternal care for hydrops fetalis, third trimester, fetus 1 20151001 22991231 O3623X2 Maternal care for hydrops fetalis, third trimester, fetus 2 20151001 22991231 O3623X3 Maternal care for hydrops fetalis, third trimester, fetus 3 20151001 22991231 O3623X4 Maternal care for hydrops fetalis, third trimester, fetus 4 20151001 22991231 O3623X5 Maternal care for hydrops fetalis, third trimester, fetus 5 20151001 22991231 O3623X9 Maternal care for hydrops fetalis, third trimester, oth 20151001 22991231 O364XX0 Maternal care for intrauterine death, not applicable or unsp 20151001 22991231 O364XX1 Maternal care for intrauterine death, fetus 1 20151001 22991231 O364XX2 Maternal care for intrauterine death, fetus 2 20151001 22991231 O364XX3 Maternal care for intrauterine death, fetus 3 20151001 22991231 O364XX4 Maternal care for intrauterine death, fetus 4 20151001 22991231 O364XX5 Maternal care for intrauterine death, fetus 5 20151001 22991231 O364XX9 Maternal care for intrauterine death, other fetus 20151001 22991231 O365110 Matern care for known or susp placntl insuff, 1st tri, unsp 20151001 22991231 O365111 Matern care for known or susp placntl insuff, 1st tri, fts1 20151001 22991231 O365112 Matern care for known or susp placntl insuff, 1st tri, fts2 20151001 22991231 O365113 Matern care for known or susp placntl insuff, 1st tri, fts3 20151001 22991231 O365114 Matern care for known or susp placntl insuff, 1st tri, fts4 20151001 22991231 O365115 Matern care for known or susp placntl insuff, 1st tri, fts5 20151001 22991231 O365119 Matern care for known or susp placntl insuff, first tri, oth 20151001 22991231 O365120 Matern care for known or susp placntl insuff, 2nd tri, unsp 20151001 22991231 O365121 Matern care for known or susp placntl insuff, 2nd tri, fts1 20151001 22991231 O365122 Matern care for known or susp placntl insuff, 2nd tri, fts2 20151001 22991231 O365123 Matern care for known or susp placntl insuff, 2nd tri, fts3 20151001 22991231 O365124 Matern care for known or susp placntl insuff, 2nd tri, fts4 20151001 22991231 O365125 Matern care for known or susp placntl insuff, 2nd tri, fts5 20151001 22991231 O365129 Matern care for known or susp placntl insuff, 2nd tri, oth 20151001 22991231 O365130 Matern care for or susp placntl insuff, third tri, unsp 20151001 22991231 O365131 Matern care for or susp placntl insuff, third tri, fts1 20151001 22991231 O365132 Matern care for or susp placntl insuff, third tri, fts2 20151001 22991231 O365133 Matern care for or susp placntl insuff, third tri, fts3 20151001 22991231 O365134 Matern care for or susp placntl insuff, third tri, fts4 20151001 22991231
82 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O365135 Matern care for or susp placntl insuff, third tri, fts5 20151001 22991231 O365139 Matern care for known or susp placntl insuff, third tri, oth 20151001 22991231 O365190 Matern care for known or susp placntl insuff, unsp tri, unsp 20151001 22991231 O365191 Matern care for known or susp placntl insuff, unsp tri, fts1 20151001 22991231 O365192 Matern care for known or susp placntl insuff, unsp tri, fts2 20151001 22991231 O365193 Matern care for known or susp placntl insuff, unsp tri, fts3 20151001 22991231 O365194 Matern care for known or susp placntl insuff, unsp tri, fts4 20151001 22991231 O365195 Matern care for known or susp placntl insuff, unsp tri, fts5 20151001 22991231 O365199 Matern care for known or susp placntl insuff, unsp tri, oth 20151001 22991231 O365910 Matern care for oth or susp poor fetl grth, 1st tri, unsp 20151001 22991231 O365911 Matern care for oth or susp poor fetl grth, 1st tri, fts1 20151001 22991231 O365912 Matern care for oth or susp poor fetl grth, 1st tri, fts2 20151001 22991231 O365913 Matern care for oth or susp poor fetl grth, 1st tri, fts3 20151001 22991231 O365914 Matern care for oth or susp poor fetl grth, 1st tri, fts4 20151001 22991231 O365915 Matern care for oth or susp poor fetl grth, 1st tri, fts5 20151001 22991231 O365919 Matern care for oth or susp poor fetl grth, 1st tri, oth 20151001 22991231 O365920 Matern care for oth or susp poor fetl grth, 2nd tri, unsp 20151001 22991231 O365921 Matern care for oth or susp poor fetl grth, 2nd tri, fts1 20151001 22991231 O365922 Matern care for oth or susp poor fetl grth, 2nd tri, fts2 20151001 22991231 O365923 Matern care for oth or susp poor fetl grth, 2nd tri, fts3 20151001 22991231 O365924 Matern care for oth or susp poor fetl grth, 2nd tri, fts4 20151001 22991231 O365925 Matern care for oth or susp poor fetl grth, 2nd tri, fts5 20151001 22991231 O365929 Matern care for oth or susp poor fetl grth, 2nd tri, oth 20151001 22991231 O365930 Matern care for oth or susp poor fetl grth, third tri, unsp 20151001 22991231 O365931 Matern care for oth or susp poor fetl grth, third tri, fts1 20151001 22991231 O365932 Matern care for oth or susp poor fetl grth, third tri, fts2 20151001 22991231 O365933 Matern care for oth or susp poor fetl grth, third tri, fts3 20151001 22991231 O365934 Matern care for oth or susp poor fetl grth, third tri, fts4 20151001 22991231 O365935 Matern care for oth or susp poor fetl grth, third tri, fts5 20151001 22991231 O365939 Matern care for oth or susp poor fetl grth, third tri, oth 20151001 22991231 O365990 Matern care for oth or susp poor fetl grth, unsp tri, unsp 20151001 22991231 O365991 Matern care for oth or susp poor fetl grth, unsp tri, fts1 20151001 22991231
83 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O365992 Matern care for oth or susp poor fetl grth, unsp tri, fts2 20151001 22991231 O365993 Matern care for oth or susp poor fetl grth, unsp tri, fts3 20151001 22991231 O365994 Matern care for oth or susp poor fetl grth, unsp tri, fts4 20151001 22991231 O365995 Matern care for oth or susp poor fetl grth, unsp tri, fts5 20151001 22991231 O365999 Matern care for oth or susp poor fetl grth, unsp tri, oth 20151001 22991231 O3660X0 Maternal care for excess fetal growth, unsp trimester, unsp 20151001 22991231 O3660X1 Maternal care for excess fetal growth, unsp tri, fetus 1 20151001 22991231 O3660X2 Maternal care for excess fetal growth, unsp tri, fetus 2 20151001 22991231 O3660X3 Maternal care for excess fetal growth, unsp tri, fetus 3 20151001 22991231 O3660X4 Maternal care for excess fetal growth, unsp tri, fetus 4 20151001 22991231 O3660X5 Maternal care for excess fetal growth, unsp tri, fetus 5 20151001 22991231 O3660X9 Maternal care for excess fetal growth, unsp trimester, oth 20151001 22991231 O3661X0 Maternal care for excess fetal growth, first trimester, unsp 20151001 22991231 O3661X1 Maternal care for excess fetal growth, first tri, fetus 1 20151001 22991231 O3661X2 Maternal care for excess fetal growth, first tri, fetus 2 20151001 22991231 O3661X3 Maternal care for excess fetal growth, first tri, fetus 3 20151001 22991231 O3661X4 Maternal care for excess fetal growth, first tri, fetus 4 20151001 22991231 O3661X5 Maternal care for excess fetal growth, first tri, fetus 5 20151001 22991231 O3661X9 Maternal care for excess fetal growth, first trimester, oth 20151001 22991231 O3662X0 Maternal care for excess fetal growth, second tri, unsp 20151001 22991231 O3662X1 Maternal care for excess fetal growth, second tri, fetus 1 20151001 22991231 O3662X2 Maternal care for excess fetal growth, second tri, fetus 2 20151001 22991231 O3662X3 Maternal care for excess fetal growth, second tri, fetus 3 20151001 22991231 O3662X4 Maternal care for excess fetal growth, second tri, fetus 4 20151001 22991231 O3662X5 Maternal care for excess fetal growth, second tri, fetus 5 20151001 22991231 O3662X9 Maternal care for excess fetal growth, second trimester, oth 20151001 22991231 O3663X0 Maternal care for excess fetal growth, third trimester, unsp 20151001 22991231 O3663X1 Maternal care for excess fetal growth, third tri, fetus 1 20151001 22991231 O3663X2 Maternal care for excess fetal growth, third tri, fetus 2 20151001 22991231 O3663X3 Maternal care for excess fetal growth, third tri, fetus 3 20151001 22991231 O3663X4 Maternal care for excess fetal growth, third tri, fetus 4 20151001 22991231 O3663X5 Maternal care for excess fetal growth, third tri, fetus 5 20151001 22991231
84 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3663X9 Maternal care for excess fetal growth, third trimester, oth 20151001 22991231 O3670X0 Maternal care for viable fetus in abd preg, unsp tri, unsp 20151001 22991231 O3670X1 Matern care for viable fetus in abd preg, unsp tri, fetus 1 20151001 22991231 O3670X2 Matern care for viable fetus in abd preg, unsp tri, fetus 2 20151001 22991231 O3670X3 Matern care for viable fetus in abd preg, unsp tri, fetus 3 20151001 22991231 O3670X4 Matern care for viable fetus in abd preg, unsp tri, fetus 4 20151001 22991231 O3670X5 Matern care for viable fetus in abd preg, unsp tri, fetus 5 20151001 22991231 O3670X9 Maternal care for viable fetus in abd preg, unsp tri, oth 20151001 22991231 O3671X0 Maternal care for viable fetus in abd preg, first tri, unsp 20151001 22991231 O3671X1 Matern care for viable fetus in abd preg, first tri, fetus 1 20151001 22991231 O3671X2 Matern care for viable fetus in abd preg, first tri, fetus 2 20151001 22991231 O3671X3 Matern care for viable fetus in abd preg, first tri, fetus 3 20151001 22991231 O3671X4 Matern care for viable fetus in abd preg, first tri, fetus 4 20151001 22991231 O3671X5 Matern care for viable fetus in abd preg, first tri, fetus 5 20151001 22991231 O3671X9 Maternal care for viable fetus in abd preg, first tri, oth 20151001 22991231 O3672X0 Maternal care for viable fetus in abd preg, second tri, unsp 20151001 22991231 O3672X1 Matern care for viable fetus in abd preg, second tri, fts1 20151001 22991231 O3672X2 Matern care for viable fetus in abd preg, second tri, fts2 20151001 22991231 O3672X3 Matern care for viable fetus in abd preg, second tri, fts3 20151001 22991231 O3672X4 Matern care for viable fetus in abd preg, second tri, fts4 20151001 22991231 O3672X5 Matern care for viable fetus in abd preg, second tri, fts5 20151001 22991231 O3672X9 Maternal care for viable fetus in abd preg, second tri, oth 20151001 22991231 O3673X0 Maternal care for viable fetus in abd preg, third tri, unsp 20151001 22991231 O3673X1 Matern care for viable fetus in abd preg, third tri, fetus 1 20151001 22991231 O3673X2 Matern care for viable fetus in abd preg, third tri, fetus 2 20151001 22991231 O3673X3 Matern care for viable fetus in abd preg, third tri, fetus 3 20151001 22991231 O3673X4 Matern care for viable fetus in abd preg, third tri, fetus 4 20151001 22991231 O3673X5 Matern care for viable fetus in abd preg, third tri, fetus 5 20151001 22991231 O3673X9 Maternal care for viable fetus in abd preg, third tri, oth 20151001 22991231 O3680X0 Pregnancy w inconclusive fetal viability, unsp 20151001 22991231 O3680X1 Pregnancy with inconclusive fetal viability, fetus 1 20151001 22991231 O3680X2 Pregnancy with inconclusive fetal viability, fetus 2 20151001 22991231
85 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3680X3 Pregnancy with inconclusive fetal viability, fetus 3 20151001 22991231 O3680X4 Pregnancy with inconclusive fetal viability, fetus 4 20151001 22991231 O3680X5 Pregnancy with inconclusive fetal viability, fetus 5 20151001 22991231 O3680X9 Pregnancy with inconclusive fetal viability, other fetus 20151001 22991231 O368120 Decreased fetal movements, second trimester, unsp 20151001 22991231 O368121 Decreased fetal movements, second trimester, fetus 1 20151001 22991231 O368122 Decreased fetal movements, second trimester, fetus 2 20151001 22991231 O368123 Decreased fetal movements, second trimester, fetus 3 20151001 22991231 O368124 Decreased fetal movements, second trimester, fetus 4 20151001 22991231 O368125 Decreased fetal movements, second trimester, fetus 5 20151001 22991231 O368129 Decreased fetal movements, second trimester, other fetus 20151001 22991231 O368130 Decreased fetal movements, third trimester, unsp 20151001 22991231 O368131 Decreased fetal movements, third trimester, fetus 1 20151001 22991231 O368132 Decreased fetal movements, third trimester, fetus 2 20151001 22991231 O368133 Decreased fetal movements, third trimester, fetus 3 20151001 22991231 O368134 Decreased fetal movements, third trimester, fetus 4 20151001 22991231 O368135 Decreased fetal movements, third trimester, fetus 5 20151001 22991231 O368139 Decreased fetal movements, third trimester, other fetus 20151001 22991231 O368190 Decreased fetal movements, unsp trimester, unsp 20151001 22991231 O368191 Decreased fetal movements, unspecified trimester, fetus 1 20151001 22991231 O368192 Decreased fetal movements, unspecified trimester, fetus 2 20151001 22991231 O368193 Decreased fetal movements, unspecified trimester, fetus 3 20151001 22991231 O368194 Decreased fetal movements, unspecified trimester, fetus 4 20151001 22991231 O368195 Decreased fetal movements, unspecified trimester, fetus 5 20151001 22991231 O368199 Decreased fetal movements, unsp trimester, other fetus 20151001 22991231 O368311 Matern care for abnlt fetl hrt rate or rhym, 1st tri, fts1 20171001 22991231 O368312 Matern care for abnlt fetl hrt rate or rhym, 1st tri, fts2 20171001 22991231 O368313 Matern care for abnlt fetl hrt rate or rhym, 1st tri, fts3 20171001 22991231 O368314 Matern care for abnlt fetl hrt rate or rhym, 1st tri, fts4 20171001 22991231 O368315 Matern care for abnlt fetl hrt rate or rhym, 1st tri, fts5 20171001 22991231 O368319 Matern care for abnlt of fetl hrt rate or rhym, 1st tri, oth 20171001 22991231 O368321 Matern care for abnlt fetl hrt rate or rhym, 2nd tri, fts1 20171001 22991231
86 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O368322 Matern care for abnlt fetl hrt rate or rhym, 2nd tri, fts2 20171001 22991231 O368323 Matern care for abnlt fetl hrt rate or rhym, 2nd tri, fts3 20171001 22991231 O368324 Matern care for abnlt fetl hrt rate or rhym, 2nd tri, fts4 20171001 22991231 O368325 Matern care for abnlt fetl hrt rate or rhym, 2nd tri, fts5 20171001 22991231 O368329 Matern care for abnlt of fetl hrt rate or rhym, 2nd tri, oth 20171001 22991231 O368331 Matern care for abnlt fetl hrt rate or rhym, 3rd tri, fts1 20171001 22991231 O368332 Matern care for abnlt fetl hrt rate or rhym, 3rd tri, fts2 20171001 22991231 O368333 Matern care for abnlt fetl hrt rate or rhym, 3rd tri, fts3 20171001 22991231 O368334 Matern care for abnlt fetl hrt rate or rhym, 3rd tri, fts4 20171001 22991231 O368335 Matern care for abnlt fetl hrt rate or rhym, 3rd tri, fts5 20171001 22991231 O368339 Matern care for abnlt of fetl hrt rate or rhym, 3rd tri, oth 20171001 22991231 O368391 Matern care for abnlt fetl hrt rate or rhym, unsp tri, fts1 20171001 22991231 O368392 Matern care for abnlt fetl hrt rate or rhym, unsp tri, fts2 20171001 22991231 O368393 Matern care for abnlt fetl hrt rate or rhym, unsp tri, fts3 20171001 22991231 O368394 Matern care for abnlt fetl hrt rate or rhym, unsp tri, fts4 20171001 22991231 O368395 Matern care for abnlt fetl hrt rate or rhym, unsp tri, fts5 20171001 22991231 O368399 Matern care for abnlt fetl hrt rate or rhym, unsp tri, oth 20171001 22991231 O368910 Maternal care for oth fetal problems, first trimester, unsp 20151001 22991231 O368911 Maternal care for oth fetal problems, first tri, fetus 1 20151001 22991231 O368912 Maternal care for oth fetal problems, first tri, fetus 2 20151001 22991231 O368913 Maternal care for oth fetal problems, first tri, fetus 3 20151001 22991231 O368914 Maternal care for oth fetal problems, first tri, fetus 4 20151001 22991231 O368915 Maternal care for oth fetal problems, first tri, fetus 5 20151001 22991231 O368919 Maternal care for oth fetal problems, first trimester, oth 20151001 22991231 O368920 Maternal care for oth fetal problems, second trimester, unsp 20151001 22991231 O368921 Maternal care for oth fetal problems, second tri, fetus 1 20151001 22991231 O368922 Maternal care for oth fetal problems, second tri, fetus 2 20151001 22991231 O368923 Maternal care for oth fetal problems, second tri, fetus 3 20151001 22991231 O368924 Maternal care for oth fetal problems, second tri, fetus 4 20151001 22991231 O368925 Maternal care for oth fetal problems, second tri, fetus 5 20151001 22991231 O368929 Maternal care for oth fetal problems, second trimester, oth 20151001 22991231 O368930 Maternal care for oth fetal problems, third trimester, unsp 20151001 22991231
87 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O368931 Maternal care for oth fetal problems, third tri, fetus 1 20151001 22991231 O368932 Maternal care for oth fetal problems, third tri, fetus 2 20151001 22991231 O368933 Maternal care for oth fetal problems, third tri, fetus 3 20151001 22991231 O368934 Maternal care for oth fetal problems, third tri, fetus 4 20151001 22991231 O368935 Maternal care for oth fetal problems, third tri, fetus 5 20151001 22991231 O368939 Maternal care for oth fetal problems, third trimester, oth 20151001 22991231 O368990 Maternal care for oth fetal problems, unsp trimester, unsp 20151001 22991231 O368991 Maternal care for oth fetal problems, unsp tri, fetus 1 20151001 22991231 O368992 Maternal care for oth fetal problems, unsp tri, fetus 2 20151001 22991231 O368993 Maternal care for oth fetal problems, unsp tri, fetus 3 20151001 22991231 O368994 Maternal care for oth fetal problems, unsp tri, fetus 4 20151001 22991231 O368995 Maternal care for oth fetal problems, unsp tri, fetus 5 20151001 22991231 O368999 Maternal care for oth fetal problems, unsp trimester, oth 20151001 22991231 O3690X0 Maternal care for fetal problem, unsp, unsp trimester, unsp 20151001 22991231 O3690X1 Maternal care for fetal problem, unsp, unsp tri, fetus 1 20151001 22991231 O3690X2 Maternal care for fetal problem, unsp, unsp tri, fetus 2 20151001 22991231 O3690X3 Maternal care for fetal problem, unsp, unsp tri, fetus 3 20151001 22991231 O3690X4 Maternal care for fetal problem, unsp, unsp tri, fetus 4 20151001 22991231 O3690X5 Maternal care for fetal problem, unsp, unsp tri, fetus 5 20151001 22991231 O3690X9 Maternal care for fetal problem, unsp, unsp trimester, oth 20151001 22991231 O3691X0 Maternal care for fetal problem, unsp, first trimester, unsp 20151001 22991231 O3691X1 Maternal care for fetal problem, unsp, first tri, fetus 1 20151001 22991231 O3691X2 Maternal care for fetal problem, unsp, first tri, fetus 2 20151001 22991231 O3691X3 Maternal care for fetal problem, unsp, first tri, fetus 3 20151001 22991231 O3691X4 Maternal care for fetal problem, unsp, first tri, fetus 4 20151001 22991231 O3691X5 Maternal care for fetal problem, unsp, first tri, fetus 5 20151001 22991231 O3691X9 Maternal care for fetal problem, unsp, first trimester, oth 20151001 22991231 O3692X0 Maternal care for fetal problem, unsp, second tri, unsp 20151001 22991231 O3692X1 Maternal care for fetal problem, unsp, second tri, fetus 1 20151001 22991231 O3692X2 Maternal care for fetal problem, unsp, second tri, fetus 2 20151001 22991231 O3692X3 Maternal care for fetal problem, unsp, second tri, fetus 3 20151001 22991231 O3692X4 Maternal care for fetal problem, unsp, second tri, fetus 4 20151001 22991231
88 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O3692X5 Maternal care for fetal problem, unsp, second tri, fetus 5 20151001 22991231 O3692X9 Maternal care for fetal problem, unsp, second trimester, oth 20151001 22991231 O3693X0 Maternal care for fetal problem, unsp, third trimester, unsp 20151001 22991231 O3693X1 Maternal care for fetal problem, unsp, third tri, fetus 1 20151001 22991231 O3693X2 Maternal care for fetal problem, unsp, third tri, fetus 2 20151001 22991231 O3693X3 Maternal care for fetal problem, unsp, third tri, fetus 3 20151001 22991231 O3693X4 Maternal care for fetal problem, unsp, third tri, fetus 4 20151001 22991231 O3693X5 Maternal care for fetal problem, unsp, third tri, fetus 5 20151001 22991231 O3693X9 Maternal care for fetal problem, unsp, third trimester, oth 20151001 22991231 O401XX0 Polyhydramnios, first trimester, not applicable or unsp 20151001 22991231 O401XX1 Polyhydramnios, first trimester, fetus 1 20151001 22991231 O401XX2 Polyhydramnios, first trimester, fetus 2 20151001 22991231 O401XX3 Polyhydramnios, first trimester, fetus 3 20151001 22991231 O401XX4 Polyhydramnios, first trimester, fetus 4 20151001 22991231 O401XX5 Polyhydramnios, first trimester, fetus 5 20151001 22991231 O401XX9 Polyhydramnios, first trimester, other fetus 20151001 22991231 O402XX0 Polyhydramnios, second trimester, not applicable or unsp 20151001 22991231 O402XX1 Polyhydramnios, second trimester, fetus 1 20151001 22991231 O402XX2 Polyhydramnios, second trimester, fetus 2 20151001 22991231 O402XX3 Polyhydramnios, second trimester, fetus 3 20151001 22991231 O402XX4 Polyhydramnios, second trimester, fetus 4 20151001 22991231 O402XX5 Polyhydramnios, second trimester, fetus 5 20151001 22991231 O402XX9 Polyhydramnios, second trimester, other fetus 20151001 22991231 O403XX0 Polyhydramnios, third trimester, not applicable or unsp 20151001 22991231 O403XX1 Polyhydramnios, third trimester, fetus 1 20151001 22991231 O403XX2 Polyhydramnios, third trimester, fetus 2 20151001 22991231 O403XX3 Polyhydramnios, third trimester, fetus 3 20151001 22991231 O403XX4 Polyhydramnios, third trimester, fetus 4 20151001 22991231 O403XX5 Polyhydramnios, third trimester, fetus 5 20151001 22991231 O403XX9 Polyhydramnios, third trimester, other fetus 20151001 22991231 O409XX0 Polyhydramnios, unsp trimester, not applicable or unsp 20151001 22991231 O409XX1 Polyhydramnios, unspecified trimester, fetus 1 20151001 22991231
89 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O409XX2 Polyhydramnios, unspecified trimester, fetus 2 20151001 22991231 O409XX3 Polyhydramnios, unspecified trimester, fetus 3 20151001 22991231 O409XX4 Polyhydramnios, unspecified trimester, fetus 4 20151001 22991231 O409XX5 Polyhydramnios, unspecified trimester, fetus 5 20151001 22991231 O409XX9 Polyhydramnios, unspecified trimester, other fetus 20151001 22991231 O4100X0 Oligohydramnios, unsp trimester, not applicable or unsp 20151001 22991231 O4100X1 Oligohydramnios, unspecified trimester, fetus 1 20151001 22991231 O4100X2 Oligohydramnios, unspecified trimester, fetus 2 20151001 22991231 O4100X3 Oligohydramnios, unspecified trimester, fetus 3 20151001 22991231 O4100X4 Oligohydramnios, unspecified trimester, fetus 4 20151001 22991231 O4100X5 Oligohydramnios, unspecified trimester, fetus 5 20151001 22991231 O4100X9 Oligohydramnios, unspecified trimester, other fetus 20151001 22991231 O4101X0 Oligohydramnios, first trimester, not applicable or unsp 20151001 22991231 O4101X1 Oligohydramnios, first trimester, fetus 1 20151001 22991231 O4101X2 Oligohydramnios, first trimester, fetus 2 20151001 22991231 O4101X3 Oligohydramnios, first trimester, fetus 3 20151001 22991231 O4101X4 Oligohydramnios, first trimester, fetus 4 20151001 22991231 O4101X5 Oligohydramnios, first trimester, fetus 5 20151001 22991231 O4101X9 Oligohydramnios, first trimester, other fetus 20151001 22991231 O4102X0 Oligohydramnios, second trimester, not applicable or unsp 20151001 22991231 O4102X1 Oligohydramnios, second trimester, fetus 1 20151001 22991231 O4102X2 Oligohydramnios, second trimester, fetus 2 20151001 22991231 O4102X3 Oligohydramnios, second trimester, fetus 3 20151001 22991231 O4102X4 Oligohydramnios, second trimester, fetus 4 20151001 22991231 O4102X5 Oligohydramnios, second trimester, fetus 5 20151001 22991231 O4102X9 Oligohydramnios, second trimester, other fetus 20151001 22991231 O4103X0 Oligohydramnios, third trimester, not applicable or unsp 20151001 22991231 O4103X1 Oligohydramnios, third trimester, fetus 1 20151001 22991231 O4103X2 Oligohydramnios, third trimester, fetus 2 20151001 22991231 O4103X3 Oligohydramnios, third trimester, fetus 3 20151001 22991231 O4103X4 Oligohydramnios, third trimester, fetus 4 20151001 22991231 O4103X5 Oligohydramnios, third trimester, fetus 5 20151001 22991231
90 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O4103X9 Oligohydramnios, third trimester, other fetus 20151001 22991231 O411010 Infct of amniotic sac and membrns, unsp, first tri, unsp 20151001 22991231 O411011 Infct of amniotic sac and membrns, unsp, first tri, fetus 1 20151001 22991231 O411012 Infct of amniotic sac and membrns, unsp, first tri, fetus 2 20151001 22991231 O411013 Infct of amniotic sac and membrns, unsp, first tri, fetus 3 20151001 22991231 O411014 Infct of amniotic sac and membrns, unsp, first tri, fetus 4 20151001 22991231 O411015 Infct of amniotic sac and membrns, unsp, first tri, fetus 5 20151001 22991231 O411019 Infct of amniotic sac and membrns, unsp, first tri, oth 20151001 22991231 O411020 Infct of amniotic sac and membrns, unsp, second tri, unsp 20151001 22991231 O411021 Infct of amniotic sac and membrns, unsp, second tri, fetus 1 20151001 22991231 O411022 Infct of amniotic sac and membrns, unsp, second tri, fetus 2 20151001 22991231 O411023 Infct of amniotic sac and membrns, unsp, second tri, fetus 3 20151001 22991231 O411024 Infct of amniotic sac and membrns, unsp, second tri, fetus 4 20151001 22991231 O411025 Infct of amniotic sac and membrns, unsp, second tri, fetus 5 20151001 22991231 O411029 Infct of amniotic sac and membrns, unsp, second tri, oth 20151001 22991231 O411030 Infct of amniotic sac and membrns, unsp, third tri, unsp 20151001 22991231 O411031 Infct of amniotic sac and membrns, unsp, third tri, fetus 1 20151001 22991231 O411032 Infct of amniotic sac and membrns, unsp, third tri, fetus 2 20151001 22991231 O411033 Infct of amniotic sac and membrns, unsp, third tri, fetus 3 20151001 22991231 O411034 Infct of amniotic sac and membrns, unsp, third tri, fetus 4 20151001 22991231 O411035 Infct of amniotic sac and membrns, unsp, third tri, fetus 5 20151001 22991231 O411039 Infct of amniotic sac and membrns, unsp, third tri, oth 20151001 22991231 O411090 Infct of amniotic sac and membrns, unsp, unsp tri, unsp 20151001 22991231 O411091 Infct of amniotic sac and membrns, unsp, unsp tri, fetus 1 20151001 22991231 O411092 Infct of amniotic sac and membrns, unsp, unsp tri, fetus 2 20151001 22991231 O411093 Infct of amniotic sac and membrns, unsp, unsp tri, fetus 3 20151001 22991231 O411094 Infct of amniotic sac and membrns, unsp, unsp tri, fetus 4 20151001 22991231 O411095 Infct of amniotic sac and membrns, unsp, unsp tri, fetus 5 20151001 22991231 O411099 Infct of amniotic sac and membrns, unsp, unsp trimester, oth 20151001 22991231 O411210 Chorioamnionitis, first trimester, not applicable or unsp 20151001 22991231 O411211 Chorioamnionitis, first trimester, fetus 1 20151001 22991231 O411212 Chorioamnionitis, first trimester, fetus 2 20151001 22991231
91 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O411213 Chorioamnionitis, first trimester, fetus 3 20151001 22991231 O411214 Chorioamnionitis, first trimester, fetus 4 20151001 22991231 O411215 Chorioamnionitis, first trimester, fetus 5 20151001 22991231 O411219 Chorioamnionitis, first trimester, other fetus 20151001 22991231 O411220 Chorioamnionitis, second trimester, not applicable or unsp 20151001 22991231 O411221 Chorioamnionitis, second trimester, fetus 1 20151001 22991231 O411222 Chorioamnionitis, second trimester, fetus 2 20151001 22991231 O411223 Chorioamnionitis, second trimester, fetus 3 20151001 22991231 O411224 Chorioamnionitis, second trimester, fetus 4 20151001 22991231 O411225 Chorioamnionitis, second trimester, fetus 5 20151001 22991231 O411229 Chorioamnionitis, second trimester, other fetus 20151001 22991231 O411230 Chorioamnionitis, third trimester, not applicable or unsp 20151001 22991231 O411231 Chorioamnionitis, third trimester, fetus 1 20151001 22991231 O411232 Chorioamnionitis, third trimester, fetus 2 20151001 22991231 O411233 Chorioamnionitis, third trimester, fetus 3 20151001 22991231 O411234 Chorioamnionitis, third trimester, fetus 4 20151001 22991231 O411235 Chorioamnionitis, third trimester, fetus 5 20151001 22991231 O411239 Chorioamnionitis, third trimester, other fetus 20151001 22991231 O411290 Chorioamnionitis, unsp trimester, not applicable or unsp 20151001 22991231 O411291 Chorioamnionitis, unspecified trimester, fetus 1 20151001 22991231 O411292 Chorioamnionitis, unspecified trimester, fetus 2 20151001 22991231 O411293 Chorioamnionitis, unspecified trimester, fetus 3 20151001 22991231 O411294 Chorioamnionitis, unspecified trimester, fetus 4 20151001 22991231 O411295 Chorioamnionitis, unspecified trimester, fetus 5 20151001 22991231 O411299 Chorioamnionitis, unspecified trimester, other fetus 20151001 22991231 O411410 Placentitis, first trimester, not applicable or unspecified 20151001 22991231 O411411 Placentitis, first trimester, fetus 1 20151001 22991231 O411412 Placentitis, first trimester, fetus 2 20151001 22991231 O411413 Placentitis, first trimester, fetus 3 20151001 22991231 O411414 Placentitis, first trimester, fetus 4 20151001 22991231 O411415 Placentitis, first trimester, fetus 5 20151001 22991231 O411419 Placentitis, first trimester, other fetus 20151001 22991231
92 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O411420 Placentitis, second trimester, not applicable or unspecified 20151001 22991231 O411421 Placentitis, second trimester, fetus 1 20151001 22991231 O411422 Placentitis, second trimester, fetus 2 20151001 22991231 O411423 Placentitis, second trimester, fetus 3 20151001 22991231 O411424 Placentitis, second trimester, fetus 4 20151001 22991231 O411425 Placentitis, second trimester, fetus 5 20151001 22991231 O411429 Placentitis, second trimester, other fetus 20151001 22991231 O411430 Placentitis, third trimester, not applicable or unspecified 20151001 22991231 O411431 Placentitis, third trimester, fetus 1 20151001 22991231 O411432 Placentitis, third trimester, fetus 2 20151001 22991231 O411433 Placentitis, third trimester, fetus 3 20151001 22991231 O411434 Placentitis, third trimester, fetus 4 20151001 22991231 O411435 Placentitis, third trimester, fetus 5 20151001 22991231 O411439 Placentitis, third trimester, other fetus 20151001 22991231 O411490 Placentitis, unsp trimester, not applicable or unspecified 20151001 22991231 O411491 Placentitis, unspecified trimester, fetus 1 20151001 22991231 O411492 Placentitis, unspecified trimester, fetus 2 20151001 22991231 O411493 Placentitis, unspecified trimester, fetus 3 20151001 22991231 O411494 Placentitis, unspecified trimester, fetus 4 20151001 22991231 O411495 Placentitis, unspecified trimester, fetus 5 20151001 22991231 O411499 Placentitis, unspecified trimester, other fetus 20151001 22991231 O418X10 Oth disrd of amniotic fluid and membrns, first tri, unsp 20151001 22991231 O418X11 Oth disrd of amniotic fluid and membrns, first tri, fetus 1 20151001 22991231 O418X12 Oth disrd of amniotic fluid and membrns, first tri, fetus 2 20151001 22991231 O418X13 Oth disrd of amniotic fluid and membrns, first tri, fetus 3 20151001 22991231 O418X14 Oth disrd of amniotic fluid and membrns, first tri, fetus 4 20151001 22991231 O418X15 Oth disrd of amniotic fluid and membrns, first tri, fetus 5 20151001 22991231 O418X19 Oth disrd of amniotic fluid and membrns, first tri, oth 20151001 22991231 O418X20 Oth disrd of amniotic fluid and membrns, second tri, unsp 20151001 22991231 O418X21 Oth disrd of amniotic fluid and membrns, second tri, fetus 1 20151001 22991231 O418X22 Oth disrd of amniotic fluid and membrns, second tri, fetus 2 20151001 22991231 O418X23 Oth disrd of amniotic fluid and membrns, second tri, fetus 3 20151001 22991231
93 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O418X24 Oth disrd of amniotic fluid and membrns, second tri, fetus 4 20151001 22991231 O418X25 Oth disrd of amniotic fluid and membrns, second tri, fetus 5 20151001 22991231 O418X29 Oth disrd of amniotic fluid and membrns, second tri, oth 20151001 22991231 O418X30 Oth disrd of amniotic fluid and membrns, third tri, unsp 20151001 22991231 O418X31 Oth disrd of amniotic fluid and membrns, third tri, fetus 1 20151001 22991231 O418X32 Oth disrd of amniotic fluid and membrns, third tri, fetus 2 20151001 22991231 O418X33 Oth disrd of amniotic fluid and membrns, third tri, fetus 3 20151001 22991231 O418X34 Oth disrd of amniotic fluid and membrns, third tri, fetus 4 20151001 22991231 O418X35 Oth disrd of amniotic fluid and membrns, third tri, fetus 5 20151001 22991231 O418X39 Oth disrd of amniotic fluid and membrns, third tri, oth 20151001 22991231 O418X90 Oth disrd of amniotic fluid and membrns, unsp tri, unsp 20151001 22991231 O418X91 Oth disrd of amniotic fluid and membrns, unsp tri, fetus 1 20151001 22991231 O418X92 Oth disrd of amniotic fluid and membrns, unsp tri, fetus 2 20151001 22991231 O418X93 Oth disrd of amniotic fluid and membrns, unsp tri, fetus 3 20151001 22991231 O418X94 Oth disrd of amniotic fluid and membrns, unsp tri, fetus 4 20151001 22991231 O418X95 Oth disrd of amniotic fluid and membrns, unsp tri, fetus 5 20151001 22991231 O418X99 Oth disrd of amniotic fluid and membrns, unsp trimester, oth 20151001 22991231 O4190X0 Disorder of amniotic fluid and membrns, unsp, unsp tri, unsp 20151001 22991231 O4190X1 Disorder of amnio fluid and membrns, unsp, unsp tri, fetus 1 20151001 22991231 O4190X2 Disorder of amnio fluid and membrns, unsp, unsp tri, fetus 2 20151001 22991231 O4190X3 Disorder of amnio fluid and membrns, unsp, unsp tri, fetus 3 20151001 22991231 O4190X4 Disorder of amnio fluid and membrns, unsp, unsp tri, fetus 4 20151001 22991231 O4190X5 Disorder of amnio fluid and membrns, unsp, unsp tri, fetus 5 20151001 22991231 O4190X9 Disorder of amniotic fluid and membrns, unsp, unsp tri, oth 20151001 22991231 O4191X0 Disorder of amnio fluid and membrns, unsp, first tri, unsp 20151001 22991231 O4191X1 Disord of amnio fluid and membrns, unsp, first tri, fetus 1 20151001 22991231 O4191X2 Disord of amnio fluid and membrns, unsp, first tri, fetus 2 20151001 22991231 O4191X3 Disord of amnio fluid and membrns, unsp, first tri, fetus 3 20151001 22991231 O4191X4 Disord of amnio fluid and membrns, unsp, first tri, fetus 4 20151001 22991231 O4191X5 Disord of amnio fluid and membrns, unsp, first tri, fetus 5 20151001 22991231 O4191X9 Disorder of amniotic fluid and membrns, unsp, first tri, oth 20151001 22991231 O4192X0 Disorder of amnio fluid and membrns, unsp, second tri, unsp 20151001 22991231
94 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O4192X1 Disord of amnio fluid and membrns, unsp, second tri, fetus 1 20151001 22991231 O4192X2 Disord of amnio fluid and membrns, unsp, second tri, fetus 2 20151001 22991231 O4192X3 Disord of amnio fluid and membrns, unsp, second tri, fetus 3 20151001 22991231 O4192X4 Disord of amnio fluid and membrns, unsp, second tri, fetus 4 20151001 22991231 O4192X5 Disord of amnio fluid and membrns, unsp, second tri, fetus 5 20151001 22991231 O4192X9 Disorder of amnio fluid and membrns, unsp, second tri, oth 20151001 22991231 O4193X0 Disorder of amnio fluid and membrns, unsp, third tri, unsp 20151001 22991231 O4193X1 Disord of amnio fluid and membrns, unsp, third tri, fetus 1 20151001 22991231 O4193X2 Disord of amnio fluid and membrns, unsp, third tri, fetus 2 20151001 22991231 O4193X3 Disord of amnio fluid and membrns, unsp, third tri, fetus 3 20151001 22991231 O4193X4 Disord of amnio fluid and membrns, unsp, third tri, fetus 4 20151001 22991231 O4193X5 Disord of amnio fluid and membrns, unsp, third tri, fetus 5 20151001 22991231 O4193X9 Disorder of amniotic fluid and membrns, unsp, third tri, oth 20151001 22991231 O4200 Prem ROM, onset labor w/n 24 hr of rupt, unsp weeks of gest 20151001 22991231 O42011 Pretrm prem ROM, onset labor w/n 24 hours of rupt, first tri 20151001 22991231 O42012 Pretrm prem ROM, onset labor w/n 24 hours of rupt, 2nd tri 20151001 22991231 O42013 Pretrm prem ROM, onset labor w/n 24 hours of rupt, third tri 20151001 22991231 O42019 Pretrm prem ROM, onset labor w/n 24 hours of rupt, unsp tri 20151001 22991231 O4202 Full-term prem ROM, onset labor within 24 hours of rupture 20151001 22991231 O4210 Prem ROM, onset labor > 24 hr fol rupt, unsp weeks of gest 20151001 22991231 O42111 Pretrm prem ROM, onset labor > 24 hours fol rupt, first tri 20151001 22991231 O42112 Pretrm prem ROM, onset labor > 24 hours fol rupt, second tri 20151001 22991231 O42113 Pretrm prem ROM, onset labor > 24 hours fol rupt, third tri 20151001 22991231 O42119 Pretrm prem ROM, onset labor > 24 hours fol rupt, unsp tri 20151001 22991231 O4212 Full-term premature ROM, onset labor > 24 hours fol rupture 20151001 22991231 O4290 Prem ROM, 7th0 betw rupt & onst labr, unsp weeks of gest 20151001 22991231 O42911 Pretrm prem ROM, unsp time betw rupt and onset labr, 1st tri 20151001 22991231 O42912 Pretrm prem ROM, unsp time betw rupt and onset labr, 2nd tri 20151001 22991231 O42913 Pretrm prem ROM, unsp time betw rupt and onst labr, 3rd tri 20151001 22991231 O42919 Pretrm prem ROM, unsp time betw rupt and onst labr, unsp tri 20151001 22991231 O4292 Full-term prem ROM, unsp time betw rupture and onset labor 20151001 22991231 O43011 Fetomaternal placental transfusion syndrome, first trimester 20151001 22991231
95 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O43012 Fetomaternal placental transfuse syndrome, second trimester 20151001 22991231 O43013 Fetomaternal placental transfusion syndrome, third trimester 20151001 22991231 O43019 Fetomaternal placental transfusion syndrome, unsp trimester 20151001 22991231 O43021 Fetus-to-fetus placental transfuse syndrome, first trimester 20151001 22991231 O43022 Fetus-to-fetus placntl transfuse syndrome, second trimester 20151001 22991231 O43023 Fetus-to-fetus placental transfuse syndrome, third trimester 20151001 22991231 O43029 Fetus-to-fetus placental transfuse syndrome, unsp trimester 20151001 22991231 O43101 Malformation of placenta, unspecified, first trimester 20151001 22991231 O43102 Malformation of placenta, unspecified, second trimester 20151001 22991231 O43103 Malformation of placenta, unspecified, third trimester 20151001 22991231 O43109 Malformation of placenta, unspecified, unspecified trimester 20151001 22991231 O43111 Circumvallate placenta, first trimester 20151001 22991231 O43112 Circumvallate placenta, second trimester 20151001 22991231 O43113 Circumvallate placenta, third trimester 20151001 22991231 O43119 Circumvallate placenta, unspecified trimester 20151001 22991231 O43121 Velamentous insertion of umbilical cord, first trimester 20151001 22991231 O43122 Velamentous insertion of umbilical cord, second trimester 20151001 22991231 O43123 Velamentous insertion of umbilical cord, third trimester 20151001 22991231 O43129 Velamentous insertion of umbilical cord, unsp trimester 20151001 22991231 O43191 Other malformation of placenta, first trimester 20151001 22991231 O43192 Other malformation of placenta, second trimester 20151001 22991231 O43193 Other malformation of placenta, third trimester 20151001 22991231 O43199 Other malformation of placenta, unspecified trimester 20151001 22991231 O43211 Placenta accreta, first trimester 20151001 22991231 O43212 Placenta accreta, second trimester 20151001 22991231 O43213 Placenta accreta, third trimester 20151001 22991231 O43219 Placenta accreta, unspecified trimester 20151001 22991231 O43221 Placenta increta, first trimester 20151001 22991231 O43222 Placenta increta, second trimester 20151001 22991231 O43223 Placenta increta, third trimester 20151001 22991231 O43229 Placenta increta, unspecified trimester 20151001 22991231 O43231 Placenta percreta, first trimester 20151001 22991231
96 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O43232 Placenta percreta, second trimester 20151001 22991231 O43233 Placenta percreta, third trimester 20151001 22991231 O43239 Placenta percreta, unspecified trimester 20151001 22991231 O43811 Placental infarction, first trimester 20151001 22991231 O43812 Placental infarction, second trimester 20151001 22991231 O43813 Placental infarction, third trimester 20151001 22991231 O43819 Placental infarction, unspecified trimester 20151001 22991231 O43891 Other placental disorders, first trimester 20151001 22991231 O43892 Other placental disorders, second trimester 20151001 22991231 O43893 Other placental disorders, third trimester 20151001 22991231 O43899 Other placental disorders, unspecified trimester 20151001 22991231 O4390 Unspecified placental disorder, unspecified trimester 20151001 22991231 O4391 Unspecified placental disorder, first trimester 20151001 22991231 O4392 Unspecified placental disorder, second trimester 20151001 22991231 O4393 Unspecified placental disorder, third trimester 20151001 22991231 O4400 Complete placenta previa NOS or without hemor, unsp tri 20151001 22991231 O4401 Complete placenta previa NOS or without hemor, first tri 20151001 22991231 O4402 Complete placenta previa NOS or without hemor, second tri 20151001 22991231 O4403 Complete placenta previa NOS or without hemor, third tri 20151001 22991231 O4410 Complete placenta previa with hemorrhage, unsp trimester 20151001 22991231 O4411 Complete placenta previa with hemorrhage, first trimester 20151001 22991231 O4412 Complete placenta previa with hemorrhage, second trimester 20151001 22991231 O4413 Complete placenta previa with hemorrhage, third trimester 20151001 22991231 O4421 Partial placenta previa NOS or without hemor, first tri 20161001 22991231 O4422 Partial placenta previa NOS or without hemor, second tri 20161001 22991231 O4423 Partial placenta previa NOS or without hemor, third tri 20161001 22991231 O4431 Partial placenta previa with hemorrhage, first trimester 20161001 22991231 O4432 Partial placenta previa with hemorrhage, second trimester 20161001 22991231 O4433 Partial placenta previa with hemorrhage, third trimester 20161001 22991231 O4441 Low lying placenta NOS or without hemor, first trimester 20161001 22991231 O4442 Low lying placenta NOS or without hemor, second trimester 20161001 22991231 O4443 Low lying placenta NOS or without hemor, third trimester 20161001 22991231
97 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O4451 Low lying placenta with hemorrhage, first trimester 20161001 22991231 O4452 Low lying placenta with hemorrhage, second trimester 20161001 22991231 O4453 Low lying placenta with hemorrhage, third trimester 20161001 22991231 O45001 Prem separtn of placenta w coag defect, unsp, first tri 20151001 22991231 O45002 Prem separtn of placenta w coag defect, unsp, second tri 20151001 22991231 O45003 Prem separtn of placenta w coag defect, unsp, third tri 20151001 22991231 O45009 Prem separtn of placenta w coag defect, unsp, unsp trimester 20151001 22991231 O45011 Prem separtn of placenta w afibrinogenemia, first trimester 20151001 22991231 O45012 Prem separtn of placenta w afibrinogenemia, second trimester 20151001 22991231 O45013 Prem separtn of placenta w afibrinogenemia, third trimester 20151001 22991231 O45019 Prem separtn of placenta w afibrinogenemia, unsp trimester 20151001 22991231 O45021 Prem separtn of placenta w dissem intravasc coag, first tri 20151001 22991231 O45022 Prem separtn of placenta w dissem intravasc coag, second tri 20151001 22991231 O45023 Prem separtn of placenta w dissem intravasc coag, third tri 20151001 22991231 O45029 Prem separtn of placenta w dissem intravasc coag, unsp tri 20151001 22991231 O45091 Prem separtn of placenta w oth coag defect, first trimester 20151001 22991231 O45092 Prem separtn of placenta w oth coag defect, second trimester 20151001 22991231 O45093 Prem separtn of placenta w oth coag defect, third trimester 20151001 22991231 O45099 Prem separtn of placenta w oth coag defect, unsp trimester 20151001 22991231 O458X1 Other premature separation of placenta, first trimester 20151001 22991231 O458X2 Other premature separation of placenta, second trimester 20151001 22991231 O458X3 Other premature separation of placenta, third trimester 20151001 22991231 O458X9 Other premature separation of placenta, unsp trimester 20151001 22991231 O4590 Premature separation of placenta, unsp, unsp trimester 20151001 22991231 O4591 Premature separation of placenta, unsp, first trimester 20151001 22991231 O4592 Premature separation of placenta, unsp, second trimester 20151001 22991231 O4593 Premature separation of placenta, unsp, third trimester 20151001 22991231 O46001 Antepartum hemorrhage w coag defect, unsp, first trimester 20151001 22991231 O46002 Antepartum hemorrhage w coag defect, unsp, second trimester 20151001 22991231 O46003 Antepartum hemorrhage w coag defect, unsp, third trimester 20151001 22991231 O46009 Antepartum hemorrhage w coag defect, unsp, unsp trimester 20151001 22991231 O46011 Antepartum hemorrhage with afibrinogenemia, first trimester 20151001 22991231
98 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O46012 Antepartum hemorrhage with afibrinogenemia, second trimester 20151001 22991231 O46013 Antepartum hemorrhage with afibrinogenemia, third trimester 20151001 22991231 O46019 Antepartum hemorrhage with afibrinogenemia, unsp trimester 20151001 22991231 O46021 Antepart hemorrhage w dissem intravasc coag, first trimester 20151001 22991231 O46022 Antepart hemor w dissem intravasc coag, second trimester 20151001 22991231 O46023 Antepart hemorrhage w dissem intravasc coag, third trimester 20151001 22991231 O46029 Antepart hemorrhage w dissem intravasc coag, unsp trimester 20151001 22991231 O46091 Antepartum hemorrhage w oth coag defect, first trimester 20151001 22991231 O46092 Antepartum hemorrhage w oth coag defect, second trimester 20151001 22991231 O46093 Antepartum hemorrhage w oth coag defect, third trimester 20151001 22991231 O46099 Antepartum hemorrhage w oth coag defect, unsp trimester 20151001 22991231 O468X1 Other antepartum hemorrhage, first trimester 20151001 22991231 O468X2 Other antepartum hemorrhage, second trimester 20151001 22991231 O468X3 Other antepartum hemorrhage, third trimester 20151001 22991231 O468X9 Other antepartum hemorrhage, unspecified trimester 20151001 22991231 O4690 Antepartum hemorrhage, unspecified, unspecified trimester 20151001 22991231 O4691 Antepartum hemorrhage, unspecified, first trimester 20151001 22991231 O4692 Antepartum hemorrhage, unspecified, second trimester 20151001 22991231 O4693 Antepartum hemorrhage, unspecified, third trimester 20151001 22991231 O4700 False labor before 37 completed weeks of gest, unsp tri 20151001 22991231 O4702 False labor before 37 completed weeks of gest, second tri 20151001 22991231 O4703 False labor before 37 completed weeks of gest, third tri 20151001 22991231 O471 False labor at or after 37 completed weeks of gestation 20151001 22991231 O479 False labor, unspecified 20151001 22991231 O480 Post-term pregnancy 20151001 22991231 O481 Prolonged pregnancy 20151001 22991231 O6000 Preterm labor without delivery, unspecified trimester 20151001 22991231 O6002 Preterm labor without delivery, second trimester 20151001 22991231 O6003 Preterm labor without delivery, third trimester 20151001 22991231 O6010X0 Preterm labor w preterm delivery, unsp trimester, unsp 20151001 22991231 O6010X1 Preterm labor with preterm delivery, unsp trimester, fetus 1 20151001 22991231 O6010X2 Preterm labor with preterm delivery, unsp trimester, fetus 2 20151001 22991231
99 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O6010X3 Preterm labor with preterm delivery, unsp trimester, fetus 3 20151001 22991231 O6010X4 Preterm labor with preterm delivery, unsp trimester, fetus 4 20151001 22991231 O6010X5 Preterm labor with preterm delivery, unsp trimester, fetus 5 20151001 22991231 O6010X9 Preterm labor w preterm delivery, unsp trimester, oth fetus 20151001 22991231 O6012X0 Preterm labor second tri w preterm delivery second tri, unsp 20151001 22991231 O6012X1 Preterm labor second tri w preterm del second tri, fetus 1 20151001 22991231 O6012X2 Preterm labor second tri w preterm del second tri, fetus 2 20151001 22991231 O6012X3 Preterm labor second tri w preterm del second tri, fetus 3 20151001 22991231 O6012X4 Preterm labor second tri w preterm del second tri, fetus 4 20151001 22991231 O6012X5 Preterm labor second tri w preterm del second tri, fetus 5 20151001 22991231 O6012X9 Preterm labor second tri w preterm delivery second tri, oth 20151001 22991231 O6013X0 Preterm labor second tri w preterm delivery third tri, unsp 20151001 22991231 O6013X1 Preterm labor second tri w preterm del third tri, fetus 1 20151001 22991231 O6013X2 Preterm labor second tri w preterm del third tri, fetus 2 20151001 22991231 O6013X3 Preterm labor second tri w preterm del third tri, fetus 3 20151001 22991231 O6013X4 Preterm labor second tri w preterm del third tri, fetus 4 20151001 22991231 O6013X5 Preterm labor second tri w preterm del third tri, fetus 5 20151001 22991231 O6013X9 Preterm labor second tri w preterm delivery third tri, oth 20151001 22991231 O6014X0 Preterm labor third tri w preterm delivery third tri, unsp 20151001 22991231 O6014X1 Preterm labor third tri w preterm del third tri, fetus 1 20151001 22991231 O6014X2 Preterm labor third tri w preterm del third tri, fetus 2 20151001 22991231 O6014X3 Preterm labor third tri w preterm del third tri, fetus 3 20151001 22991231 O6014X4 Preterm labor third tri w preterm del third tri, fetus 4 20151001 22991231 O6014X5 Preterm labor third tri w preterm del third tri, fetus 5 20151001 22991231 O6014X9 Preterm labor third tri w preterm delivery third tri, oth 20151001 22991231 O6020X0 Term delivery w preterm labor, unsp trimester, unsp 20151001 22991231 O6020X1 Term delivery with preterm labor, unsp trimester, fetus 1 20151001 22991231 O6020X2 Term delivery with preterm labor, unsp trimester, fetus 2 20151001 22991231 O6020X3 Term delivery with preterm labor, unsp trimester, fetus 3 20151001 22991231 O6020X4 Term delivery with preterm labor, unsp trimester, fetus 4 20151001 22991231 O6020X5 Term delivery with preterm labor, unsp trimester, fetus 5 20151001 22991231 O6020X9 Term delivery with preterm labor, unsp trimester, oth fetus 20151001 22991231
100 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O6022X0 Term delivery w preterm labor, second trimester, unsp 20151001 22991231 O6022X1 Term delivery with preterm labor, second trimester, fetus 1 20151001 22991231 O6022X2 Term delivery with preterm labor, second trimester, fetus 2 20151001 22991231 O6022X3 Term delivery with preterm labor, second trimester, fetus 3 20151001 22991231 O6022X4 Term delivery with preterm labor, second trimester, fetus 4 20151001 22991231 O6022X5 Term delivery with preterm labor, second trimester, fetus 5 20151001 22991231 O6022X9 Term delivery w preterm labor, second trimester, oth fetus 20151001 22991231 O6023X0 Term delivery w preterm labor, third trimester, unsp 20151001 22991231 O6023X1 Term delivery with preterm labor, third trimester, fetus 1 20151001 22991231 O6023X2 Term delivery with preterm labor, third trimester, fetus 2 20151001 22991231 O6023X3 Term delivery with preterm labor, third trimester, fetus 3 20151001 22991231 O6023X4 Term delivery with preterm labor, third trimester, fetus 4 20151001 22991231 O6023X5 Term delivery with preterm labor, third trimester, fetus 5 20151001 22991231 O6023X9 Term delivery with preterm labor, third trimester, oth fetus 20151001 22991231 O610 Failed medical induction of labor 20151001 22991231 O611 Failed instrumental induction of labor 20151001 22991231 O618 Other failed induction of labor 20151001 22991231 O619 Failed induction of labor, unspecified 20151001 22991231 O620 Primary inadequate contractions 20151001 22991231 O621 Secondary uterine inertia 20151001 22991231 O622 Other uterine inertia 20151001 22991231 O623 Precipitate labor 20151001 22991231 O624 Hypertonic, incoordinate, and prolonged uterine contractions 20151001 22991231 O628 Other abnormalities of forces of labor 20151001 22991231 O629 Abnormality of forces of labor, unspecified 20151001 22991231 O630 Prolonged first stage (of labor) 20151001 22991231 O631 Prolonged second stage (of labor) 20151001 22991231 O632 Delayed delivery of second twin, triplet, etc. 20151001 22991231 O639 Long labor, unspecified 20151001 22991231 O640XX0 Obstructed labor due to incmpl rotation of fetal head, unsp 20151001 22991231 O640XX1 Obst labor due to incmpl rotation of fetal head, fetus 1 20151001 22991231 O640XX2 Obst labor due to incmpl rotation of fetal head, fetus 2 20151001 22991231
101 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O640XX3 Obst labor due to incmpl rotation of fetal head, fetus 3 20151001 22991231 O640XX4 Obst labor due to incmpl rotation of fetal head, fetus 4 20151001 22991231 O640XX5 Obst labor due to incmpl rotation of fetal head, fetus 5 20151001 22991231 O640XX9 Obstructed labor due to incmpl rotation of fetal head, oth 20151001 22991231 O641XX0 Obstructed labor due to breech presentation, unsp 20151001 22991231 O641XX1 Obstructed labor due to breech presentation, fetus 1 20151001 22991231 O641XX2 Obstructed labor due to breech presentation, fetus 2 20151001 22991231 O641XX3 Obstructed labor due to breech presentation, fetus 3 20151001 22991231 O641XX4 Obstructed labor due to breech presentation, fetus 4 20151001 22991231 O641XX5 Obstructed labor due to breech presentation, fetus 5 20151001 22991231 O641XX9 Obstructed labor due to breech presentation, other fetus 20151001 22991231 O642XX0 Obstructed labor due to face presentation, unsp 20151001 22991231 O642XX1 Obstructed labor due to face presentation, fetus 1 20151001 22991231 O642XX2 Obstructed labor due to face presentation, fetus 2 20151001 22991231 O642XX3 Obstructed labor due to face presentation, fetus 3 20151001 22991231 O642XX4 Obstructed labor due to face presentation, fetus 4 20151001 22991231 O642XX5 Obstructed labor due to face presentation, fetus 5 20151001 22991231 O642XX9 Obstructed labor due to face presentation, other fetus 20151001 22991231 O643XX0 Obstructed labor due to brow presentation, unsp 20151001 22991231 O643XX1 Obstructed labor due to brow presentation, fetus 1 20151001 22991231 O643XX2 Obstructed labor due to brow presentation, fetus 2 20151001 22991231 O643XX3 Obstructed labor due to brow presentation, fetus 3 20151001 22991231 O643XX4 Obstructed labor due to brow presentation, fetus 4 20151001 22991231 O643XX5 Obstructed labor due to brow presentation, fetus 5 20151001 22991231 O643XX9 Obstructed labor due to brow presentation, other fetus 20151001 22991231 O644XX0 Obstructed labor due to shoulder presentation, unsp 20151001 22991231 O644XX1 Obstructed labor due to shoulder presentation, fetus 1 20151001 22991231 O644XX2 Obstructed labor due to shoulder presentation, fetus 2 20151001 22991231 O644XX3 Obstructed labor due to shoulder presentation, fetus 3 20151001 22991231 O644XX4 Obstructed labor due to shoulder presentation, fetus 4 20151001 22991231 O644XX5 Obstructed labor due to shoulder presentation, fetus 5 20151001 22991231 O644XX9 Obstructed labor due to shoulder presentation, other fetus 20151001 22991231
102 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O645XX0 Obstructed labor due to compound presentation, unsp 20151001 22991231 O645XX1 Obstructed labor due to compound presentation, fetus 1 20151001 22991231 O645XX2 Obstructed labor due to compound presentation, fetus 2 20151001 22991231 O645XX3 Obstructed labor due to compound presentation, fetus 3 20151001 22991231 O645XX4 Obstructed labor due to compound presentation, fetus 4 20151001 22991231 O645XX5 Obstructed labor due to compound presentation, fetus 5 20151001 22991231 O645XX9 Obstructed labor due to compound presentation, other fetus 20151001 22991231 O648XX0 Obstructed labor due to oth malposition and malpresent, unsp 20151001 22991231 O648XX1 Obstructed labor due to oth malpos and malpresent, fetus 1 20151001 22991231 O648XX2 Obstructed labor due to oth malpos and malpresent, fetus 2 20151001 22991231 O648XX3 Obstructed labor due to oth malpos and malpresent, fetus 3 20151001 22991231 O648XX4 Obstructed labor due to oth malpos and malpresent, fetus 4 20151001 22991231 O648XX5 Obstructed labor due to oth malpos and malpresent, fetus 5 20151001 22991231 O648XX9 Obstructed labor due to oth malposition and malpresent, oth 20151001 22991231 O649XX0 Obstructed labor due to malpos and malpresent, unsp, unsp 20151001 22991231 O649XX1 Obstructed labor due to malpos and malpresent, unsp, fetus 1 20151001 22991231 O649XX2 Obstructed labor due to malpos and malpresent, unsp, fetus 2 20151001 22991231 O649XX3 Obstructed labor due to malpos and malpresent, unsp, fetus 3 20151001 22991231 O649XX4 Obstructed labor due to malpos and malpresent, unsp, fetus 4 20151001 22991231 O649XX5 Obstructed labor due to malpos and malpresent, unsp, fetus 5 20151001 22991231 O649XX9 Obstructed labor due to malpos and malpresent, unsp, oth 20151001 22991231 O650 Obstructed labor due to deformed pelvis 20151001 22991231 O651 Obstructed labor due to generally contracted pelvis 20151001 22991231 O652 Obstructed labor due to pelvic inlet contraction 20151001 22991231 O653 Obst labor due to pelvic outlet and mid-cavity contrctn 20151001 22991231 O654 Obstructed labor due to fetopelvic disproportion, unsp 20151001 22991231 O655 Obstructed labor due to abnlt of maternal pelvic organs 20151001 22991231 O658 Obstructed labor due to other maternal pelvic abnormalities 20151001 22991231 O659 Obstructed labor due to maternal pelvic abnormality, unsp 20151001 22991231 O660 Obstructed labor due to shoulder dystocia 20151001 22991231 O661 Obstructed labor due to locked twins 20151001 22991231 O662 Obstructed labor due to unusually large fetus 20151001 22991231
103 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O663 Obstructed labor due to other abnormalities of fetus 20151001 22991231 O6640 Failed trial of labor, unspecified 20151001 22991231 O6641 Failed attempt vaginal birth after previous cesarean del 20151001 22991231 O665 Attempted application of vacuum extractor and forceps 20151001 22991231 O666 Obstructed labor due to other multiple fetuses 20151001 22991231 O668 Other specified obstructed labor 20151001 22991231 O669 Obstructed labor, unspecified 20151001 22991231 O670 Intrapartum hemorrhage with coagulation defect 20151001 22991231 O678 Other intrapartum hemorrhage 20151001 22991231 O679 Intrapartum hemorrhage, unspecified 20151001 22991231 O68 Labor and delivery comp by abnlt of fetal acid-base balance 20151001 22991231 O690XX0 Labor and delivery complicated by prolapse of cord, unsp 20151001 22991231 O690XX1 Labor and delivery complicated by prolapse of cord, fetus 1 20151001 22991231 O690XX2 Labor and delivery complicated by prolapse of cord, fetus 2 20151001 22991231 O690XX3 Labor and delivery complicated by prolapse of cord, fetus 3 20151001 22991231 O690XX4 Labor and delivery complicated by prolapse of cord, fetus 4 20151001 22991231 O690XX5 Labor and delivery complicated by prolapse of cord, fetus 5 20151001 22991231 O690XX9 Labor and delivery complicated by prolapse of cord, oth 20151001 22991231 O691XX0 Labor and delivery comp by cord around neck, w comprsn, unsp 20151001 22991231 O691XX1 Labor and del comp by cord around neck, w comprsn, fetus 1 20151001 22991231 O691XX2 Labor and del comp by cord around neck, w comprsn, fetus 2 20151001 22991231 O691XX3 Labor and del comp by cord around neck, w comprsn, fetus 3 20151001 22991231 O691XX4 Labor and del comp by cord around neck, w comprsn, fetus 4 20151001 22991231 O691XX5 Labor and del comp by cord around neck, w comprsn, fetus 5 20151001 22991231 O691XX9 Labor and delivery comp by cord around neck, w comprsn, oth 20151001 22991231 O692XX0 Labor and del comp by oth cord entangle, w comprsn, unsp 20151001 22991231 O692XX1 Labor and del comp by oth cord entangle, w comprsn, fetus 1 20151001 22991231 O692XX2 Labor and del comp by oth cord entangle, w comprsn, fetus 2 20151001 22991231 O692XX3 Labor and del comp by oth cord entangle, w comprsn, fetus 3 20151001 22991231 O692XX4 Labor and del comp by oth cord entangle, w comprsn, fetus 4 20151001 22991231 O692XX5 Labor and del comp by oth cord entangle, w comprsn, fetus 5 20151001 22991231 O692XX9 Labor and delivery comp by oth cord entangle, w comprsn, oth 20151001 22991231
104 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O693XX0 Labor and delivery complicated by short cord, unsp 20151001 22991231 O693XX1 Labor and delivery complicated by short cord, fetus 1 20151001 22991231 O693XX2 Labor and delivery complicated by short cord, fetus 2 20151001 22991231 O693XX3 Labor and delivery complicated by short cord, fetus 3 20151001 22991231 O693XX4 Labor and delivery complicated by short cord, fetus 4 20151001 22991231 O693XX5 Labor and delivery complicated by short cord, fetus 5 20151001 22991231 O693XX9 Labor and delivery complicated by short cord, other fetus 20151001 22991231 O694XX0 Labor and delivery complicated by vasa previa, unsp 20151001 22991231 O694XX1 Labor and delivery complicated by vasa previa, fetus 1 20151001 22991231 O694XX2 Labor and delivery complicated by vasa previa, fetus 2 20151001 22991231 O694XX3 Labor and delivery complicated by vasa previa, fetus 3 20151001 22991231 O694XX4 Labor and delivery complicated by vasa previa, fetus 4 20151001 22991231 O694XX5 Labor and delivery complicated by vasa previa, fetus 5 20151001 22991231 O694XX9 Labor and delivery complicated by vasa previa, other fetus 20151001 22991231 O695XX0 Labor and delivery comp by vascular lesion of cord, unsp 20151001 22991231 O695XX1 Labor and delivery comp by vascular lesion of cord, fetus 1 20151001 22991231 O695XX2 Labor and delivery comp by vascular lesion of cord, fetus 2 20151001 22991231 O695XX3 Labor and delivery comp by vascular lesion of cord, fetus 3 20151001 22991231 O695XX4 Labor and delivery comp by vascular lesion of cord, fetus 4 20151001 22991231 O695XX5 Labor and delivery comp by vascular lesion of cord, fetus 5 20151001 22991231 O695XX9 Labor and delivery comp by vascular lesion of cord, oth 20151001 22991231 O6981X0 Labor and del comp by cord around neck, w/o comprsn, unsp 20151001 22991231 O6981X1 Labor and del comp by cord around neck, w/o comprsn, fetus 1 20151001 22991231 O6981X2 Labor and del comp by cord around neck, w/o comprsn, fetus 2 20151001 22991231 O6981X3 Labor and del comp by cord around neck, w/o comprsn, fetus 3 20151001 22991231 O6981X4 Labor and del comp by cord around neck, w/o comprsn, fetus 4 20151001 22991231 O6981X5 Labor and del comp by cord around neck, w/o comprsn, fetus 5 20151001 22991231 O6981X9 Labor and del comp by cord around neck, w/o comprsn, oth 20151001 22991231 O6982X0 Labor and del comp by oth cord entangle, w/o comprsn, unsp 20151001 22991231 O6982X1 Labor and del comp by oth cord entangle, w/o comprsn, fts1 20151001 22991231 O6982X2 Labor and del comp by oth cord entangle, w/o comprsn, fts2 20151001 22991231 O6982X3 Labor and del comp by oth cord entangle, w/o comprsn, fts3 20151001 22991231
105 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O6982X4 Labor and del comp by oth cord entangle, w/o comprsn, fts4 20151001 22991231 O6982X5 Labor and del comp by oth cord entangle, w/o comprsn, fts5 20151001 22991231 O6982X9 Labor and del comp by oth cord entangle, w/o comprsn, oth 20151001 22991231 O6989X0 Labor and delivery complicated by oth cord comp, unsp 20151001 22991231 O6989X1 Labor and delivery complicated by oth cord comp, fetus 1 20151001 22991231 O6989X2 Labor and delivery complicated by oth cord comp, fetus 2 20151001 22991231 O6989X3 Labor and delivery complicated by oth cord comp, fetus 3 20151001 22991231 O6989X4 Labor and delivery complicated by oth cord comp, fetus 4 20151001 22991231 O6989X5 Labor and delivery complicated by oth cord comp, fetus 5 20151001 22991231 O6989X9 Labor and delivery complicated by oth cord comp, oth 20151001 22991231 O699XX0 Labor and delivery complicated by cord comp, unsp, unsp 20151001 22991231 O699XX1 Labor and delivery complicated by cord comp, unsp, fetus 1 20151001 22991231 O699XX2 Labor and delivery complicated by cord comp, unsp, fetus 2 20151001 22991231 O699XX3 Labor and delivery complicated by cord comp, unsp, fetus 3 20151001 22991231 O699XX4 Labor and delivery complicated by cord comp, unsp, fetus 4 20151001 22991231 O699XX5 Labor and delivery complicated by cord comp, unsp, fetus 5 20151001 22991231 O699XX9 Labor and delivery complicated by cord comp, unsp, oth 20151001 22991231 O700 First degree perineal laceration during delivery 20151001 22991231 O701 Second degree perineal laceration during delivery 20151001 22991231 O702 Third degree perineal laceration during delivery 20151001 20160930 O7021 Third degree perineal laceration during delivery, IIIa 20161001 22991231 O7022 Third degree perineal laceration during delivery, IIIb 20161001 22991231 O7023 Third degree perineal laceration during delivery, IIIc 20161001 22991231 O703 Fourth degree perineal laceration during delivery 20151001 22991231 O704 Anal sphincter tear comp del, not assoc w third degree lac 20151001 22991231 O709 Perineal laceration during delivery, unspecified 20151001 22991231 O7100 Rupture of uterus before onset of labor, unsp trimester 20151001 22991231 O7102 Rupture of uterus before onset of labor, second trimester 20151001 22991231 O7103 Rupture of uterus before onset of labor, third trimester 20151001 22991231 O711 Rupture of uterus during labor 20151001 22991231 O712 Postpartum inversion of uterus 20151001 22991231 O713 Obstetric laceration of cervix 20151001 22991231
106 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O714 Obstetric high vaginal laceration alone 20151001 22991231 O715 Other obstetric injury to pelvic organs 20151001 22991231 O716 Obstetric damage to pelvic joints and ligaments 20151001 22991231 O717 Obstetric hematoma of pelvis 20151001 22991231 O7181 Laceration of uterus, not elsewhere classified 20151001 22991231 O7182 Other specified trauma to perineum and vulva 20151001 22991231 O7189 Other specified obstetric trauma 20151001 22991231 O719 Obstetric trauma, unspecified 20151001 22991231 O720 Third-stage hemorrhage 20151001 22991231 O721 Other immediate postpartum hemorrhage 20151001 22991231 O722 Delayed and secondary postpartum hemorrhage 20151001 22991231 O723 Postpartum coagulation defects 20151001 22991231 O730 Retained placenta without hemorrhage 20151001 22991231 O731 Retained portions of placenta and membranes, w/o hemorrhage 20151001 22991231 O740 Aspirat pneumonitis due to anesth during labor and delivery 20151001 22991231 O741 Oth pulmonary comp of anesthesia during labor and delivery 20151001 22991231 O742 Cardiac comp of anesthesia during labor and delivery 20151001 22991231 O743 Cnsl complications of anesthesia during labor and delivery 20151001 22991231 O744 Toxic reaction to local anesthesia during labor and delivery 20151001 22991231 O745 Spinal and epidur anesthesia-induced hdache dur labr and del 20151001 22991231 O746 Oth comp of spinal and epidural anesth during labor and del 20151001 22991231 O747 Failed or difficult intubation for anesth dur labor and del 20151001 22991231 O748 Other complications of anesthesia during labor and delivery 20151001 22991231 O749 Complication of anesthesia during labor and delivery, unsp 20151001 22991231 O750 Maternal distress during labor and delivery 20151001 22991231 O751 Shock during or following labor and delivery 20151001 22991231 O752 Pyrexia during labor, not elsewhere classified 20151001 22991231 O753 Other infection during labor 20151001 22991231 O754 Other complications of obstetric surgery and procedures 20151001 22991231 O755 Delayed delivery after artificial rupture of membranes 20151001 22991231 O7581 Maternal exhaustion complicating labor and delivery 20151001 22991231 O7582 Onset labor 37-39 weeks, w del by (planned) cesarean section 20151001 22991231
107 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O7589 Other specified complications of labor and delivery 20151001 22991231 O759 Complication of labor and delivery, unspecified 20151001 22991231 O76 Abnlt in fetal heart rate and rhythm comp labor and delivery 20151001 22991231 O770 Labor and delivery complicated by meconium in amniotic fluid 20151001 22991231 O771 Fetal stress in labor or delivery due to drug administration 20151001 22991231 O778 Labor and delivery comp by oth evidence of fetal stress 20151001 22991231 O779 Labor and delivery complicated by fetal stress, unspecified 20151001 22991231 O80 Encounter for full-term uncomplicated delivery 20151001 22991231 O82 Encounter for cesarean delivery without indication 20151001 22991231 O85 Puerperal sepsis 20151001 22991231 O860 Infection of obstetric surgical wound 20151001 20180930 O8600 Infection of obstetric surgical wound, unspecified 20181001 22991231 O8601 Infct of obstetric surgical wound, superfic incisional site 20181001 22991231 O8602 Infection of obstetric surgical wound, deep incisional site 20181001 22991231 O8603 Infection of obstetric surgical wound, organ and space site 20181001 22991231 O8604 Sepsis following an obstetrical procedure 20181001 22991231 O8609 Infection of obstetric surgical wound, other surgical site 20181001 22991231 O8611 Cervicitis following delivery 20151001 22991231 O8612 Endometritis following delivery 20151001 22991231 O8613 Vaginitis following delivery 20151001 22991231 O8619 Other infection of genital tract following delivery 20151001 22991231 O8620 Urinary tract infection following delivery, unspecified 20151001 22991231 O8621 Infection of kidney following delivery 20151001 22991231 O8622 Infection of bladder following delivery 20151001 22991231 O8629 Other urinary tract infection following delivery 20151001 22991231 O864 Pyrexia of unknown origin following delivery 20151001 22991231 O8681 Puerperal septic thrombophlebitis 20151001 22991231 O8689 Other specified puerperal infections 20151001 22991231 O870 Superficial thrombophlebitis in the puerperium 20151001 22991231 O871 Deep phlebothrombosis in the puerperium 20151001 22991231 O872 Hemorrhoids in the puerperium 20151001 22991231 O873 Cerebral venous thrombosis in the puerperium 20151001 22991231
108 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O874 Varicose veins of lower extremity in the puerperium 20151001 22991231 O878 Other venous complications in the puerperium 20151001 22991231 O879 Venous complication in the puerperium, unspecified 20151001 22991231 O88011 Air embolism in pregnancy, first trimester 20151001 22991231 O88012 Air embolism in pregnancy, second trimester 20151001 22991231 O88013 Air embolism in pregnancy, third trimester 20151001 22991231 O88019 Air embolism in pregnancy, unspecified trimester 20151001 22991231 O8802 Air embolism in childbirth 20151001 22991231 O8803 Air embolism in the puerperium 20151001 22991231 O88111 Amniotic fluid embolism in pregnancy, first trimester 20151001 22991231 O88112 Amniotic fluid embolism in pregnancy, second trimester 20151001 22991231 O88113 Amniotic fluid embolism in pregnancy, third trimester 20151001 22991231 O88119 Amniotic fluid embolism in pregnancy, unspecified trimester 20151001 22991231 O8812 Amniotic fluid embolism in childbirth 20151001 22991231 O8813 Amniotic fluid embolism in the puerperium 20151001 22991231 O88211 Thromboembolism in pregnancy, first trimester 20151001 22991231 O88212 Thromboembolism in pregnancy, second trimester 20151001 22991231 O88213 Thromboembolism in pregnancy, third trimester 20151001 22991231 O88219 Thromboembolism in pregnancy, unspecified trimester 20151001 22991231 O8822 Thromboembolism in childbirth 20151001 22991231 O8823 Thromboembolism in the puerperium 20151001 22991231 O88311 Pyemic and septic embolism in pregnancy, first trimester 20151001 22991231 O88312 Pyemic and septic embolism in pregnancy, second trimester 20151001 22991231 O88313 Pyemic and septic embolism in pregnancy, third trimester 20151001 22991231 O88319 Pyemic and septic embolism in pregnancy, unsp trimester 20151001 22991231 O8832 Pyemic and septic embolism in childbirth 20151001 22991231 O8833 Pyemic and septic embolism in the puerperium 20151001 22991231 O88811 Other embolism in pregnancy, first trimester 20151001 22991231 O88812 Other embolism in pregnancy, second trimester 20151001 22991231 O88813 Other embolism in pregnancy, third trimester 20151001 22991231 O88819 Other embolism in pregnancy, unspecified trimester 20151001 22991231 O8882 Other embolism in childbirth 20151001 22991231
109 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O8883 Other embolism in the puerperium 20151001 22991231 O8901 Aspiration pneumonitis due to anesth during the puerperium 20151001 22991231 O8909 Oth pulmonary comp of anesthesia during the puerperium 20151001 22991231 O891 Cardiac complications of anesthesia during the puerperium 20151001 22991231 O892 Cnsl complications of anesthesia during the puerperium 20151001 22991231 O893 Toxic reaction to local anesthesia during the puerperium 20151001 22991231 O894 Spinal and epidur anesthesia-induced hdache during the puerp 20151001 22991231 O895 Oth comp of spinal and epidural anesth during the puerperium 20151001 22991231 O896 Failed or difficult intubation for anesth during the puerp 20151001 22991231 O898 Other complications of anesthesia during the puerperium 20151001 22991231 O899 Complication of anesthesia during the puerperium, unsp 20151001 22991231 O900 Disruption of cesarean delivery wound 20151001 22991231 O901 Disruption of perineal obstetric wound 20151001 22991231 O902 Hematoma of obstetric wound 20151001 22991231 O903 Peripartum cardiomyopathy 20151001 22991231 O904 Postpartum acute kidney failure 20151001 22991231 O905 Postpartum thyroiditis 20151001 22991231 O906 Postpartum mood disturbance 20151001 22991231 O9081 Anemia of the puerperium 20151001 22991231 O9089 Oth complications of the puerperium, NEC 20151001 22991231 O909 Complication of the puerperium, unspecified 20151001 22991231 O91011 Infection of nipple associated w pregnancy, first trimester 20151001 22991231 O91012 Infection of nipple associated w pregnancy, second trimester 20151001 22991231 O91013 Infection of nipple associated w pregnancy, third trimester 20151001 22991231 O91019 Infection of nipple associated w pregnancy, unsp trimester 20151001 22991231 O9102 Infection of nipple associated with the puerperium 20151001 22991231 O9103 Infection of nipple associated with lactation 20151001 22991231 O91111 Abscess of breast associated with pregnancy, first trimester 20151001 22991231 O91112 Abscess of breast associated w pregnancy, second trimester 20151001 22991231 O91113 Abscess of breast associated with pregnancy, third trimester 20151001 22991231 O91119 Abscess of breast associated with pregnancy, unsp trimester 20151001 22991231 O9112 Abscess of breast associated with the puerperium 20151001 22991231
110 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O9113 Abscess of breast associated with lactation 20151001 22991231 O91211 Nonpurulent mastitis associated w pregnancy, first trimester 20151001 22991231 O91212 Nonpurulent mastitis assoc w pregnancy, second trimester 20151001 22991231 O91213 Nonpurulent mastitis associated w pregnancy, third trimester 20151001 22991231 O91219 Nonpurulent mastitis associated w pregnancy, unsp trimester 20151001 22991231 O9122 Nonpurulent mastitis associated with the puerperium 20151001 22991231 O9123 Nonpurulent mastitis associated with lactation 20151001 22991231 O92011 Retracted nipple associated with pregnancy, first trimester 20151001 22991231 O92012 Retracted nipple associated with pregnancy, second trimester 20151001 22991231 O92013 Retracted nipple associated with pregnancy, third trimester 20151001 22991231 O92019 Retracted nipple associated with pregnancy, unsp trimester 20151001 22991231 O9202 Retracted nipple associated with the puerperium 20151001 22991231 O9203 Retracted nipple associated with lactation 20151001 22991231 O92111 Cracked nipple associated with pregnancy, first trimester 20151001 22991231 O92112 Cracked nipple associated with pregnancy, second trimester 20151001 22991231 O92113 Cracked nipple associated with pregnancy, third trimester 20151001 22991231 O92119 Cracked nipple associated with pregnancy, unsp trimester 20151001 22991231 O9212 Cracked nipple associated with the puerperium 20151001 22991231 O9213 Cracked nipple associated with lactation 20151001 22991231 O9220 Unsp disorder of breast assoc w pregnancy and the puerperium 20151001 22991231 O9229 Oth disorders of breast assoc w pregnancy and the puerperium 20151001 22991231 O923 Agalactia 20151001 22991231 O924 Hypogalactia 20151001 22991231 O925 Suppressed lactation 20151001 22991231 O926 Galactorrhea 20151001 22991231 O9270 Unspecified disorders of lactation 20151001 22991231 O9279 Other disorders of lactation 20151001 22991231 O98011 Tuberculosis complicating pregnancy, first trimester 20151001 22991231 O98012 Tuberculosis complicating pregnancy, second trimester 20151001 22991231 O98013 Tuberculosis complicating pregnancy, third trimester 20151001 22991231 O98019 Tuberculosis complicating pregnancy, unspecified trimester 20151001 22991231 O9802 Tuberculosis complicating childbirth 20151001 22991231
111 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O9803 Tuberculosis complicating the puerperium 20151001 22991231 O98111 Syphilis complicating pregnancy, first trimester 20151001 22991231 O98112 Syphilis complicating pregnancy, second trimester 20151001 22991231 O98113 Syphilis complicating pregnancy, third trimester 20151001 22991231 O98119 Syphilis complicating pregnancy, unspecified trimester 20151001 22991231 O9812 Syphilis complicating childbirth 20151001 22991231 O9813 Syphilis complicating the puerperium 20151001 22991231 O98211 Gonorrhea complicating pregnancy, first trimester 20151001 22991231 O98212 Gonorrhea complicating pregnancy, second trimester 20151001 22991231 O98213 Gonorrhea complicating pregnancy, third trimester 20151001 22991231 O98219 Gonorrhea complicating pregnancy, unspecified trimester 20151001 22991231 O9822 Gonorrhea complicating childbirth 20151001 22991231 O9823 Gonorrhea complicating the puerperium 20151001 22991231 O98311 Oth infect w sexl mode of transmiss comp preg, first tri 20151001 22991231 O98312 Oth infect w sexl mode of transmiss comp preg, second tri 20151001 22991231 O98313 Oth infect w sexl mode of transmiss comp preg, third tri 20151001 22991231 O98319 Oth infect w sexl mode of transmiss comp preg, unsp tri 20151001 22991231 O9832 Oth infections w sexl mode of transmiss comp childbirth 20151001 22991231 O9833 Oth infections w sexl mode of transmiss comp the puerperium 20151001 22991231 O98411 Viral hepatitis complicating pregnancy, first trimester 20151001 22991231 O98412 Viral hepatitis complicating pregnancy, second trimester 20151001 22991231 O98413 Viral hepatitis complicating pregnancy, third trimester 20151001 22991231 O98419 Viral hepatitis complicating pregnancy, unsp trimester 20151001 22991231 O9842 Viral hepatitis complicating childbirth 20151001 22991231 O9843 Viral hepatitis complicating the puerperium 20151001 22991231 O98511 Other viral diseases complicating pregnancy, first trimester 20151001 22991231 O98512 Oth viral diseases complicating pregnancy, second trimester 20151001 22991231 O98513 Other viral diseases complicating pregnancy, third trimester 20151001 22991231 O98519 Other viral diseases complicating pregnancy, unsp trimester 20151001 22991231 O9852 Other viral diseases complicating childbirth 20151001 22991231 O9853 Other viral diseases complicating the puerperium 20151001 22991231 O98611 Protozoal diseases complicating pregnancy, first trimester 20151001 22991231
112 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O98612 Protozoal diseases complicating pregnancy, second trimester 20151001 22991231 O98613 Protozoal diseases complicating pregnancy, third trimester 20151001 22991231 O98619 Protozoal diseases complicating pregnancy, unsp trimester 20151001 22991231 O9862 Protozoal diseases complicating childbirth 20151001 22991231 O9863 Protozoal diseases complicating the puerperium 20151001 22991231 O98711 Human immunodef virus disease comp preg, first trimester 20151001 22991231 O98712 Human immunodef virus disease comp preg, second trimester 20151001 22991231 O98713 Human immunodef virus disease comp preg, third trimester 20151001 22991231 O98719 Human immunodef virus disease comp pregnancy, unsp trimester 20151001 22991231 O9872 Human immunodeficiency virus disease complicating childbirth 20151001 22991231 O9873 Human immunodef virus disease complicating the puerperium 20151001 22991231 O98811 Oth maternal infec/parastc diseases comp preg, first tri 20151001 22991231 O98812 Oth maternal infec/parastc diseases comp preg, second tri 20151001 22991231 O98813 Oth maternal infec/parastc diseases comp preg, third tri 20151001 22991231 O98819 Oth maternal infec/parastc diseases comp preg, unsp tri 20151001 22991231 O9882 Oth maternal infec/parastc diseases complicating childbirth 20151001 22991231 O9883 Oth maternal infec/parastc diseases comp the puerperium 20151001 22991231 O98911 Unsp maternal infec/parastc disease comp preg, first tri 20151001 22991231 O98912 Unsp maternal infec/parastc disease comp preg, second tri 20151001 22991231 O98913 Unsp maternal infec/parastc disease comp preg, third tri 20151001 22991231 O98919 Unsp maternal infec/parastc disease comp preg, unsp tri 20151001 22991231 O9892 Unsp maternal infec/parastc disease complicating childbirth 20151001 22991231 O9893 Unsp maternal infec/parastc disease comp the puerperium 20151001 22991231 O99011 Anemia complicating pregnancy, first trimester 20151001 22991231 O99012 Anemia complicating pregnancy, second trimester 20151001 22991231 O99013 Anemia complicating pregnancy, third trimester 20151001 22991231 O99019 Anemia complicating pregnancy, unspecified trimester 20151001 22991231 O9902 Anemia complicating childbirth 20151001 22991231 O9903 Anemia complicating the puerperium 20151001 22991231 O99111 Oth dis of bld/bld-form org/immun mechnsm comp preg, 1st tri 20151001 22991231 O99112 Oth dis of bld/bld-form org/immun mechnsm comp preg, 2nd tri 20151001 22991231 O99113 Oth dis of bld/bld-form org/immun mechnsm comp preg, 3rd tri 20151001 22991231
113 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O99119 Oth dis of bld/bld-form org/immun mechnsm comp preg,unsp tri 20151001 22991231 O9912 Oth dis of the bld/bld-form org/immun mechnsm comp chldbrth 20151001 22991231 O9913 Oth dis of the bld/bld-form org/immun mechnsm comp the puerp 20151001 22991231 O99210 Obesity complicating pregnancy, unspecified trimester 20151001 22991231 O99211 Obesity complicating pregnancy, first trimester 20151001 22991231 O99212 Obesity complicating pregnancy, second trimester 20151001 22991231 O99213 Obesity complicating pregnancy, third trimester 20151001 22991231 O99214 Obesity complicating childbirth 20151001 22991231 O99215 Obesity complicating the puerperium 20151001 22991231 O99280 Endo, nutritional and metab diseases comp preg, unsp tri 20151001 22991231 O99281 Endo, nutritional and metab diseases comp preg, first tri 20151001 22991231 O99282 Endo, nutritional and metab diseases comp preg, second tri 20151001 22991231 O99283 Endo, nutritional and metab diseases comp preg, third tri 20151001 22991231 O99284 Endocrine, nutritional and metabolic diseases comp chldbrth 20151001 22991231 O99285 Endocrine, nutritional and metabolic diseases comp the puerp 20151001 22991231 O99310 Alcohol use complicating pregnancy, unspecified trimester 20151001 22991231 O99311 Alcohol use complicating pregnancy, first trimester 20151001 22991231 O99312 Alcohol use complicating pregnancy, second trimester 20151001 22991231 O99313 Alcohol use complicating pregnancy, third trimester 20151001 22991231 O99314 Alcohol use complicating childbirth 20151001 22991231 O99315 Alcohol use complicating the puerperium 20151001 22991231 O99320 Drug use complicating pregnancy, unspecified trimester 20151001 22991231 O99321 Drug use complicating pregnancy, first trimester 20151001 22991231 O99322 Drug use complicating pregnancy, second trimester 20151001 22991231 O99323 Drug use complicating pregnancy, third trimester 20151001 22991231 O99324 Drug use complicating childbirth 20151001 22991231 O99325 Drug use complicating the puerperium 20151001 22991231 O99330 Smoking (tobacco) complicating pregnancy, unsp trimester 20151001 22991231 O99331 Smoking (tobacco) complicating pregnancy, first trimester 20151001 22991231 O99332 Smoking (tobacco) complicating pregnancy, second trimester 20151001 22991231 O99333 Smoking (tobacco) complicating pregnancy, third trimester 20151001 22991231 O99334 Smoking (tobacco) complicating childbirth 20151001 22991231
114 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O99335 Smoking (tobacco) complicating the puerperium 20151001 22991231 O99340 Oth mental disorders complicating pregnancy, unsp trimester 20151001 22991231 O99341 Oth mental disorders complicating pregnancy, first trimester 20151001 22991231 O99342 Oth mental disorders comp pregnancy, second trimester 20151001 22991231 O99343 Oth mental disorders complicating pregnancy, third trimester 20151001 22991231 O99344 Other mental disorders complicating childbirth 20151001 22991231 O99345 Other mental disorders complicating the puerperium 20151001 22991231 O99350 Diseases of the nervous sys comp pregnancy, unsp trimester 20151001 22991231 O99351 Diseases of the nervous sys comp pregnancy, first trimester 20151001 22991231 O99352 Diseases of the nervous sys comp pregnancy, second trimester 20151001 22991231 O99353 Diseases of the nervous sys comp pregnancy, third trimester 20151001 22991231 O99354 Diseases of the nervous system complicating childbirth 20151001 22991231 O99355 Diseases of the nervous system complicating the puerperium 20151001 22991231 O99411 Diseases of the circ sys comp pregnancy, first trimester 20151001 22991231 O99412 Diseases of the circ sys comp pregnancy, second trimester 20151001 22991231 O99413 Diseases of the circ sys comp pregnancy, third trimester 20151001 22991231 O99419 Diseases of the circ sys comp pregnancy, unsp trimester 20151001 22991231 O9942 Diseases of the circulatory system complicating childbirth 20151001 22991231 O9943 Diseases of the circ sys complicating the puerperium 20151001 22991231 O99511 Diseases of the resp sys comp pregnancy, first trimester 20151001 22991231 O99512 Diseases of the resp sys comp pregnancy, second trimester 20151001 22991231 O99513 Diseases of the resp sys comp pregnancy, third trimester 20151001 22991231 O99519 Diseases of the resp sys comp pregnancy, unsp trimester 20151001 22991231 O9952 Diseases of the respiratory system complicating childbirth 20151001 22991231 O9953 Diseases of the resp sys complicating the puerperium 20151001 22991231 O99611 Diseases of the dgstv sys comp pregnancy, first trimester 20151001 22991231 O99612 Diseases of the dgstv sys comp pregnancy, second trimester 20151001 22991231 O99613 Diseases of the dgstv sys comp pregnancy, third trimester 20151001 22991231 O99619 Diseases of the dgstv sys comp pregnancy, unsp trimester 20151001 22991231 O9962 Diseases of the digestive system complicating childbirth 20151001 22991231 O9963 Diseases of the digestive system complicating the puerperium 20151001 22991231 O99711 Diseases of the skin, subcu comp pregnancy, first trimester 20151001 22991231
115 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O99712 Diseases of the skin, subcu comp pregnancy, second trimester 20151001 22991231 O99713 Diseases of the skin, subcu comp pregnancy, third trimester 20151001 22991231 O99719 Diseases of the skin, subcu comp pregnancy, unsp trimester 20151001 22991231 O9972 Diseases of the skin, subcu complicating childbirth 20151001 22991231 O9973 Diseases of the skin, subcu complicating the puerperium 20151001 22991231 O99810 Abnormal glucose complicating pregnancy 20151001 22991231 O99814 Abnormal glucose complicating childbirth 20151001 22991231 O99815 Abnormal glucose complicating the puerperium 20151001 22991231 O99820 Streptococcus B carrier state complicating pregnancy 20151001 22991231 O99824 Streptococcus B carrier state complicating childbirth 20151001 22991231 O99825 Streptococcus B carrier state complicating the puerperium 20151001 22991231 O99830 Other infection carrier state complicating pregnancy 20151001 22991231 O99834 Other infection carrier state complicating childbirth 20151001 22991231 O99835 Other infection carrier state complicating the puerperium 20151001 22991231 O99840 Bariatric surgery status comp pregnancy, unsp trimester 20151001 22991231 O99841 Bariatric surgery status comp pregnancy, first trimester 20151001 22991231 O99842 Bariatric surgery status comp pregnancy, second trimester 20151001 22991231 O99843 Bariatric surgery status comp pregnancy, third trimester 20151001 22991231 O99844 Bariatric surgery status complicating childbirth 20151001 22991231 O99845 Bariatric surgery status complicating the puerperium 20151001 22991231 O9989 Oth diseases and conditions compl preg/chldbrth 20151001 20200930 O99891 Oth diseases and conditions complicating pregnancy 20201001 22991231 O99892 Oth diseases and conditions complicating childbirth 20201001 22991231 O99893 Oth diseases and conditions complicating puerperium 20201001 22991231 O9A111 Malignant neoplasm complicating pregnancy, first trimester 20151001 22991231 O9A112 Malignant neoplasm complicating pregnancy, second trimester 20151001 22991231 O9A113 Malignant neoplasm complicating pregnancy, third trimester 20151001 22991231 O9A119 Malignant neoplasm complicating pregnancy, unsp trimester 20151001 22991231 O9A12 Malignant neoplasm complicating childbirth 20151001 22991231 O9A13 Malignant neoplasm complicating the puerperium 20151001 22991231 O9A211 Inj/poisn/oth conseq of external causes comp preg, first tri 20151001 22991231 O9A212 Inj/poisn/oth conseq of extrn causes comp preg, second tri 20151001 22991231
116 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes O9A213 Inj/poisn/oth conseq of external causes comp preg, third tri 20151001 22991231 O9A219 Inj/poisn/oth conseq of external causes comp preg, unsp tri 20151001 22991231 O9A22 Inj/poisn/oth conseq of external causes comp childbirth 20151001 22991231 O9A23 Inj/poisn/oth conseq of external causes comp the puerperium 20151001 22991231 O9A311 Physical abuse complicating pregnancy, first trimester 20151001 22991231 O9A312 Physical abuse complicating pregnancy, second trimester 20151001 22991231 O9A313 Physical abuse complicating pregnancy, third trimester 20151001 22991231 O9A319 Physical abuse complicating pregnancy, unspecified trimester 20151001 22991231 O9A32 Physical abuse complicating childbirth 20151001 22991231 O9A33 Physical abuse complicating the puerperium 20151001 22991231 O9A411 Sexual abuse complicating pregnancy, first trimester 20151001 22991231 O9A412 Sexual abuse complicating pregnancy, second trimester 20151001 22991231 O9A413 Sexual abuse complicating pregnancy, third trimester 20151001 22991231 O9A419 Sexual abuse complicating pregnancy, unspecified trimester 20151001 22991231 O9A42 Sexual abuse complicating childbirth 20151001 22991231 O9A43 Sexual abuse complicating the puerperium 20151001 22991231 O9A511 Psychological abuse complicating pregnancy, first trimester 20151001 22991231 O9A512 Psychological abuse complicating pregnancy, second trimester 20151001 22991231 O9A513 Psychological abuse complicating pregnancy, third trimester 20151001 22991231 O9A519 Psychological abuse complicating pregnancy, unsp trimester 20151001 22991231 O9A52 Psychological abuse complicating childbirth 20151001 22991231 O9A53 Psychological abuse complicating the puerperium 20151001 22991231 Z331 Pregnant state, incidental 20151001 22991231 Z3400 Encntr for suprvsn of normal first pregnancy, unsp trimester 20151001 22991231 Z3401 Encntr for suprvsn of normal first preg, first trimester 20151001 22991231 Z3402 Encntr for suprvsn of normal first preg, second trimester 20151001 22991231 Z3403 Encntr for suprvsn of normal first preg, third trimester 20151001 22991231 Z3480 Encounter for suprvsn of normal pregnancy, unsp trimester 20151001 22991231 Z3481 Encounter for suprvsn of normal pregnancy, first trimester 20151001 22991231 Z3482 Encounter for suprvsn of normal pregnancy, second trimester 20151001 22991231 Z3483 Encounter for suprvsn of normal pregnancy, third trimester 20151001 22991231 Z3490 Encntr for suprvsn of normal pregnancy, unsp, unsp trimester 20151001 22991231
117 Table 9 ICD-10-CM Diagnosis Codes for OBS ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes Z3491 Encntr for suprvsn of normal preg, unsp, first trimester 20151001 22991231 Z3492 Encntr for suprvsn of normal preg, unsp, second trimester 20151001 22991231 Z3493 Encntr for suprvsn of normal preg, unsp, third trimester 20151001 22991231 Z36 Encounter for antenatal screening of mother 20151001 20170930 Z360 Encounter for antenatal screening for chromosomal anomalies 20171001 22991231 Z361 Enctr for antenat screen for raised alphafetoprotein level 20171001 22991231 Z362 Encounter for other antenatal screening follow-up 20171001 22991231 Z363 Encounter for antenatal screening for malformations 20171001 22991231 Z364 Enctr for antenatal screening for fetal growth retardation 20171001 22991231 Z365 Encounter for antenatal screening for isoimmunization 20171001 22991231 Z3681 Encounter for antenatal screening for hydrops fetalis 20171001 22991231 Z3682 Encounter for antenatal screening for nuchal translucency 20171001 22991231 Z3683 Encounter for fetal screening for congenital cardiac abnlt 20171001 22991231 Z3684 Encounter for antenatal screening for fetal lung maturity 20171001 22991231 Z3685 Encounter for antenatal screening for Streptococcus B 20171001 22991231 Z3686 Encounter for antenatal screening for cervical length 20171001 22991231 Z3687 Encounter for antenatal screening for uncertain dates 20171001 22991231 Z3688 Encounter for antenatal screening for fetal macrosomia 20171001 22991231 Z3689 Encounter for other specified antenatal screening 20171001 22991231 Z368A Encounter for antenatal screening for other genetic defects 20171001 22991231 Z390 Encntr for care and exam of mother immediately after del 20151001 22991231 Z391 Encounter for care and examination of lactating mother 20151001 22991231 Z392 Encounter for routine postpartum follow-up 20151001 22991231
118 Table Listing, Previous Table 9, Next Table 11, End of Document
Table 10: ICD-10-CM Behavioral Health Diagnosis Codes
Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F0281 Dementia in oth diseases classd elswhr w behavioral disturb 20151001 22991231 F0391 Unspecified dementia with behavioral disturbance 20151001 22991231 F060 Psychotic disorder w hallucin due to known physiol condition 20151001 22991231 F061 Catatonic disorder due to known physiological condition 20151001 22991231 F062 Psychotic disorder w delusions due to known physiol cond 20151001 22991231 F0630 Mood disorder due to known physiological condition, unsp 20151001 22991231 F0631 Mood disorder due to known physiol cond w depressv features 20151001 22991231 F0632 Mood disord d/t physiol cond w major depressive-like epsd 20151001 22991231 F0633 Mood disorder due to known physiol cond w manic features 20151001 22991231 F0634 Mood disorder due to known physiol cond w mixed features 20151001 22991231 F064 Anxiety disorder due to known physiological condition 20151001 22991231 F068 Oth mental disorders due to known physiological condition 20151001 22991231 F070 Personality change due to known physiological condition 20151001 22991231 F0789 Oth personality & behavrl disord due to known physiol cond 20151001 22991231 F1010 Alcohol abuse, uncomplicated 20151001 22991231 F1011 Alcohol abuse, in remission 20171001 22991231 F10120 Alcohol abuse with intoxication, uncomplicated 20151001 22991231 F10121 Alcohol abuse with intoxication delirium 20151001 22991231 F10129 Alcohol abuse with intoxication, unspecified 20151001 22991231 F10130 Alcohol abuse with withdrawal, uncomplicated 20201001 22991231 F10131 Alcohol abuse with withdrawal delirium 20201001 22991231 F10132 Alcohol abuse with withdrawal with perceptual disturbance 20201001 22991231 F10139 Alcohol abuse with withdrawal, unspecified 20201001 22991231 F1014 Alcohol abuse with alcohol-induced mood disorder 20151001 22991231 F10150 Alcohol abuse w alcoh-induce psychotic disorder w delusions 20151001 22991231 F10151 Alcohol abuse w alcoh-induce psychotic disorder w hallucin 20151001 22991231 F10159 Alcohol abuse with alcohol-induced psychotic disorder, unsp 20151001 22991231 F10180 Alcohol abuse with alcohol-induced anxiety disorder 20151001 22991231
119 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F10181 Alcohol abuse with alcohol-induced sexual dysfunction 20151001 22991231 F10182 Alcohol abuse with alcohol-induced sleep disorder 20151001 22991231 F10188 Alcohol abuse with other alcohol-induced disorder 20151001 22991231 F1019 Alcohol abuse with unspecified alcohol-induced disorder 20151001 22991231 F1020 Alcohol dependence, uncomplicated 20151001 22991231 F1021 Alcohol dependence, in remission 20151001 22991231 F10220 Alcohol dependence with intoxication, uncomplicated 20151001 22991231 F10221 Alcohol dependence with intoxication delirium 20151001 22991231 F10229 Alcohol dependence with intoxication, unspecified 20151001 22991231 F10230 Alcohol dependence with withdrawal, uncomplicated 20151001 22991231 F10231 Alcohol dependence with withdrawal delirium 20151001 22991231 F10232 Alcohol dependence w withdrawal with perceptual disturbance 20151001 22991231 F10239 Alcohol dependence with withdrawal, unspecified 20151001 22991231 F1024 Alcohol dependence with alcohol-induced mood disorder 20151001 22991231 F10250 Alcohol depend w alcoh-induce psychotic disorder w delusions 20151001 22991231 F10251 Alcohol depend w alcoh-induce psychotic disorder w hallucin 20151001 22991231 F10259 Alcohol dependence w alcoh-induce psychotic disorder, unsp 20151001 22991231 F1026 Alcohol depend w alcoh-induce persisting amnestic disorder 20151001 22991231 F1027 Alcohol dependence with alcohol-induced persisting dementia 20151001 22991231 F10280 Alcohol dependence with alcohol-induced anxiety disorder 20151001 22991231 F10281 Alcohol dependence with alcohol-induced sexual dysfunction 20151001 22991231 F10282 Alcohol dependence with alcohol-induced sleep disorder 20151001 22991231 F10288 Alcohol dependence with other alcohol-induced disorder 20151001 22991231 F1029 Alcohol dependence with unspecified alcohol-induced disorder 20151001 22991231 F10920 Alcohol use, unspecified with intoxication, uncomplicated 20151001 22991231 F10921 Alcohol use, unspecified with intoxication delirium 20151001 22991231 F10929 Alcohol use, unspecified with intoxication, unspecified 20151001 22991231 F10930 Alcohol use, unspecified with withdrawal, uncomplicated 20201001 22991231 F10931 Alcohol use, unspecified with withdrawal delirium 20201001 22991231 F10932 Alcohol use, unspecified with w/drawal w perceptual disturb 20201001 22991231 F10939 Alcohol use, unspecified with withdrawal, unspecified 20201001 22991231 F1094 Alcohol use, unspecified with alcohol-induced mood disorder 20151001 22991231
120 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F10950 Alcohol use, unsp w alcoh-induce psych disorder w delusions 20151001 22991231 F10951 Alcohol use, unsp w alcoh-induce psych disorder w hallucin 20151001 22991231 F10959 Alcohol use, unsp w alcohol-induced psychotic disorder, unsp 20151001 22991231 F1096 Alcohol use, unsp w alcoh-induce persist amnestic disorder 20151001 22991231 F1097 Alcohol use, unsp with alcohol-induced persisting dementia 20151001 22991231 F10980 Alcohol use, unsp with alcohol-induced anxiety disorder 20151001 22991231 F10981 Alcohol use, unsp with alcohol-induced sexual dysfunction 20151001 22991231 F10982 Alcohol use, unspecified with alcohol-induced sleep disorder 20151001 22991231 F10988 Alcohol use, unspecified with other alcohol-induced disorder 20151001 22991231 F1099 Alcohol use, unsp with unspecified alcohol-induced disorder 20151001 22991231 F1110 Opioid abuse, uncomplicated 20151001 22991231 F1111 Opioid abuse, in remission 20171001 22991231 F11120 Opioid abuse with intoxication, uncomplicated 20151001 22991231 F11121 Opioid abuse with intoxication delirium 20151001 22991231 F11122 Opioid abuse with intoxication with perceptual disturbance 20151001 22991231 F11129 Opioid abuse with intoxication, unspecified 20151001 22991231 F1113 Opioid abuse with withdrawal 20201001 22991231 F1114 Opioid abuse with opioid-induced mood disorder 20151001 22991231 F11150 Opioid abuse w opioid-induced psychotic disorder w delusions 20151001 22991231 F11151 Opioid abuse w opioid-induced psychotic disorder w hallucin 20151001 22991231 F11159 Opioid abuse with opioid-induced psychotic disorder, unsp 20151001 22991231 F11181 Opioid abuse with opioid-induced sexual dysfunction 20151001 22991231 F11182 Opioid abuse with opioid-induced sleep disorder 20151001 22991231 F11188 Opioid abuse with other opioid-induced disorder 20151001 22991231 F1119 Opioid abuse with unspecified opioid-induced disorder 20151001 22991231 F1120 Opioid dependence, uncomplicated 20151001 22991231 F1121 Opioid dependence, in remission 20151001 22991231 F11220 Opioid dependence with intoxication, uncomplicated 20151001 22991231 F11221 Opioid dependence with intoxication delirium 20151001 22991231 F11222 Opioid dependence w intoxication with perceptual disturbance 20151001 22991231 F11229 Opioid dependence with intoxication, unspecified 20151001 22991231 F1123 Opioid dependence with withdrawal 20151001 22991231
121 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F1124 Opioid dependence with opioid-induced mood disorder 20151001 22991231 F11250 Opioid depend w opioid-induc psychotic disorder w delusions 20151001 22991231 F11251 Opioid depend w opioid-induc psychotic disorder w hallucin 20151001 22991231 F11259 Opioid dependence w opioid-induced psychotic disorder, unsp 20151001 22991231 F11281 Opioid dependence with opioid-induced sexual dysfunction 20151001 22991231 F11282 Opioid dependence with opioid-induced sleep disorder 20151001 22991231 F11288 Opioid dependence with other opioid-induced disorder 20151001 22991231 F1129 Opioid dependence with unspecified opioid-induced disorder 20151001 22991231 F1190 Opioid use, unspecified, uncomplicated 20151001 22991231 F11920 Opioid use, unspecified with intoxication, uncomplicated 20151001 22991231 F11921 Opioid use, unspecified with intoxication delirium 20151001 22991231 F11922 Opioid use, unsp w intoxication with perceptual disturbance 20151001 22991231 F11929 Opioid use, unspecified with intoxication, unspecified 20151001 22991231 F1193 Opioid use, unspecified with withdrawal 20151001 22991231 F1194 Opioid use, unspecified with opioid-induced mood disorder 20151001 22991231 F11950 Opioid use, unsp w opioid-induc psych disorder w delusions 20151001 22991231 F11951 Opioid use, unsp w opioid-induc psych disorder w hallucin 20151001 22991231 F11959 Opioid use, unsp w opioid-induced psychotic disorder, unsp 20151001 22991231 F11981 Opioid use, unsp with opioid-induced sexual dysfunction 20151001 22991231 F11982 Opioid use, unspecified with opioid-induced sleep disorder 20151001 22991231 F11988 Opioid use, unspecified with other opioid-induced disorder 20151001 22991231 F1199 Opioid use, unsp with unspecified opioid-induced disorder 20151001 22991231 F1210 Cannabis abuse, uncomplicated 20151001 22991231 F1211 Cannabis abuse, in remission 20171001 22991231 F12120 Cannabis abuse with intoxication, uncomplicated 20151001 22991231 F12121 Cannabis abuse with intoxication delirium 20151001 22991231 F12122 Cannabis abuse with intoxication with perceptual disturbance 20151001 22991231 F12129 Cannabis abuse with intoxication, unspecified 20151001 22991231 F1213 Cannabis abuse with withdrawal 20201001 22991231 F12150 Cannabis abuse with psychotic disorder with delusions 20151001 22991231 F12151 Cannabis abuse with psychotic disorder with hallucinations 20151001 22991231 F12159 Cannabis abuse with psychotic disorder, unspecified 20151001 22991231
122 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F12180 Cannabis abuse with cannabis-induced anxiety disorder 20151001 22991231 F12188 Cannabis abuse with other cannabis-induced disorder 20151001 22991231 F1219 Cannabis abuse with unspecified cannabis-induced disorder 20151001 22991231 F1220 Cannabis dependence, uncomplicated 20151001 22991231 F1221 Cannabis dependence, in remission 20151001 22991231 F12220 Cannabis dependence with intoxication, uncomplicated 20151001 22991231 F12221 Cannabis dependence with intoxication delirium 20151001 22991231 F12222 Cannabis dependence w intoxication w perceptual disturbance 20151001 22991231 F12229 Cannabis dependence with intoxication, unspecified 20151001 22991231 F1223 Cannabis dependence with withdrawal 20181001 22991231 F12250 Cannabis dependence with psychotic disorder with delusions 20151001 22991231 F12251 Cannabis dependence w psychotic disorder with hallucinations 20151001 22991231 F12259 Cannabis dependence with psychotic disorder, unspecified 20151001 22991231 F12280 Cannabis dependence with cannabis-induced anxiety disorder 20151001 22991231 F12288 Cannabis dependence with other cannabis-induced disorder 20151001 22991231 F1229 Cannabis dependence with unsp cannabis-induced disorder 20151001 22991231 F1290 Cannabis use, unspecified, uncomplicated 20151001 22991231 F12920 Cannabis use, unspecified with intoxication, uncomplicated 20151001 22991231 F12921 Cannabis use, unspecified with intoxication delirium 20151001 22991231 F12922 Cannabis use, unsp w intoxication w perceptual disturbance 20151001 22991231 F12929 Cannabis use, unspecified with intoxication, unspecified 20151001 22991231 F1293 Cannabis use, unspecified with withdrawal 20181001 22991231 F12950 Cannabis use, unsp with psychotic disorder with delusions 20151001 22991231 F12951 Cannabis use, unsp w psychotic disorder with hallucinations 20151001 22991231 F12959 Cannabis use, unsp with psychotic disorder, unspecified 20151001 22991231 F12980 Cannabis use, unspecified with anxiety disorder 20151001 22991231 F12988 Cannabis use, unsp with other cannabis-induced disorder 20151001 22991231 F1299 Cannabis use, unsp with unsp cannabis-induced disorder 20151001 22991231 F1310 Sedative, hypnotic or anxiolytic abuse, uncomplicated 20151001 22991231 F1311 Sedative, hypnotic or anxiolytic abuse, in remission 20171001 22991231 F13120 Sedatv/hyp/anxiolytc abuse w intoxication, uncomplicated 20151001 22991231 F13121 Sedatv/hyp/anxiolytc abuse w intoxication delirium 20151001 22991231
123 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F13129 Sedative, hypnotic or anxiolytic abuse w intoxication, unsp 20151001 22991231 F13130 Sedatv/hyp/anxiolytc abuse with withdrawal, uncomplicated 20201001 22991231 F13131 Sedatv/hyp/anxiolytc abuse with withdrawal delirium 20201001 22991231 F13132 Sedatv/hyp/anxiolytc abuse with w/drawal w perceptl disturb 20201001 22991231 F13139 Sedatv/hyp/anxiolytc abuse with withdrawal, unspecified 20201001 22991231 F1314 Sedative, hypnotic or anxiolytic abuse w mood disorder 20151001 22991231 F13150 Sedatv/hyp/anxiolytc abuse w psychotic disorder w delusions 20151001 22991231 F13151 Sedatv/hyp/anxiolytc abuse w psychotic disorder w hallucin 20151001 22991231 F13159 Sedatv/hyp/anxiolytc abuse w psychotic disorder, unsp 20151001 22991231 F13180 Sedative, hypnotic or anxiolytic abuse w anxiety disorder 20151001 22991231 F13181 Sedative, hypnotic or anxiolytic abuse w sexual dysfunction 20151001 22991231 F13182 Sedative, hypnotic or anxiolytic abuse w sleep disorder 20151001 22991231 F13188 Sedative, hypnotic or anxiolytic abuse w oth disorder 20151001 22991231 F1319 Sedative, hypnotic or anxiolytic abuse w unsp disorder 20151001 22991231 F1320 Sedative, hypnotic or anxiolytic dependence, uncomplicated 20151001 22991231 F1321 Sedative, hypnotic or anxiolytic dependence, in remission 20151001 22991231 F13220 Sedatv/hyp/anxiolytc dependence w intoxication, uncomp 20151001 22991231 F13221 Sedatv/hyp/anxiolytc dependence w intoxication delirium 20151001 22991231 F13229 Sedatv/hyp/anxiolytc dependence w intoxication, unsp 20151001 22991231 F13230 Sedatv/hyp/anxiolytc dependence w withdrawal, uncomplicated 20151001 22991231 F13231 Sedatv/hyp/anxiolytc dependence w withdrawal delirium 20151001 22991231 F13232 Sedatv/hyp/anxiolytc depend w w/drawal w perceptual disturb 20151001 22991231 F13239 Sedatv/hyp/anxiolytc dependence w withdrawal, unsp 20151001 22991231 F1324 Sedative, hypnotic or anxiolytic dependence w mood disorder 20151001 22991231 F13250 Sedatv/hyp/anxiolytc depend w psychotic disorder w delusions 20151001 22991231 F13251 Sedatv/hyp/anxiolytc depend w psychotic disorder w hallucin 20151001 22991231 F13259 Sedatv/hyp/anxiolytc dependence w psychotic disorder, unsp 20151001 22991231 F1326 Sedatv/hyp/anxiolytc depend w persisting amnestic disorder 20151001 22991231 F1327 Sedatv/hyp/anxiolytc dependence w persisting dementia 20151001 22991231 F13280 Sedatv/hyp/anxiolytc dependence w anxiety disorder 20151001 22991231 F13281 Sedatv/hyp/anxiolytc dependence w sexual dysfunction 20151001 22991231 F13282 Sedative, hypnotic or anxiolytic dependence w sleep disorder 20151001 22991231
124 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F13288 Sedative, hypnotic or anxiolytic dependence w oth disorder 20151001 22991231 F1329 Sedative, hypnotic or anxiolytic dependence w unsp disorder 20151001 22991231 F1390 Sedative, hypnotic, or anxiolytic use, unsp, uncomplicated 20151001 22991231 F13920 Sedatv/hyp/anxiolytc use, unsp w intoxication, uncomplicated 20151001 22991231 F13921 Sedatv/hyp/anxiolytc use, unsp w intoxication delirium 20151001 22991231 F13929 Sedatv/hyp/anxiolytc use, unsp w intoxication, unsp 20151001 22991231 F13930 Sedatv/hyp/anxiolytc use, unsp w withdrawal, uncomplicated 20151001 22991231 F13931 Sedatv/hyp/anxiolytc use, unsp w withdrawal delirium 20151001 22991231 F13932 Sedatv/hyp/anxiolytc use, unsp w w/drawal w perceptl disturb 20151001 22991231 F13939 Sedatv/hyp/anxiolytc use, unsp w withdrawal, unsp 20151001 22991231 F1394 Sedative, hypnotic or anxiolytic use, unsp w mood disorder 20151001 22991231 F13950 Sedatv/hyp/anxiolytc use, unsp w psych disorder w delusions 20151001 22991231 F13951 Sedatv/hyp/anxiolytc use, unsp w psych disorder w hallucin 20151001 22991231 F13959 Sedatv/hyp/anxiolytc use, unsp w psychotic disorder, unsp 20151001 22991231 F1396 Sedatv/hyp/anxiolytc use, unsp w persist amnestic disorder 20151001 22991231 F1397 Sedatv/hyp/anxiolytc use, unsp w persisting dementia 20151001 22991231 F13980 Sedatv/hyp/anxiolytc use, unsp w anxiety disorder 20151001 22991231 F13981 Sedatv/hyp/anxiolytc use, unsp w sexual dysfunction 20151001 22991231 F13982 Sedative, hypnotic or anxiolytic use, unsp w sleep disorder 20151001 22991231 F13988 Sedative, hypnotic or anxiolytic use, unsp w oth disorder 20151001 22991231 F1399 Sedative, hypnotic or anxiolytic use, unsp w unsp disorder 20151001 22991231 F1410 Cocaine abuse, uncomplicated 20151001 22991231 F1411 Cocaine abuse, in remission 20171001 22991231 F14120 Cocaine abuse with intoxication, uncomplicated 20151001 22991231 F14121 Cocaine abuse with intoxication with delirium 20151001 22991231 F14122 Cocaine abuse with intoxication with perceptual disturbance 20151001 22991231 F14129 Cocaine abuse with intoxication, unspecified 20151001 22991231 F1413 Cocaine abuse, unspecified with withdrawal 20201001 22991231 F1414 Cocaine abuse with cocaine-induced mood disorder 20151001 22991231 F14150 Cocaine abuse w cocaine-induc psychotic disorder w delusions 20151001 22991231 F14151 Cocaine abuse w cocaine-induc psychotic disorder w hallucin 20151001 22991231 F14159 Cocaine abuse with cocaine-induced psychotic disorder, unsp 20151001 22991231
125 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F14180 Cocaine abuse with cocaine-induced anxiety disorder 20151001 22991231 F14181 Cocaine abuse with cocaine-induced sexual dysfunction 20151001 22991231 F14182 Cocaine abuse with cocaine-induced sleep disorder 20151001 22991231 F14188 Cocaine abuse with other cocaine-induced disorder 20151001 22991231 F1419 Cocaine abuse with unspecified cocaine-induced disorder 20151001 22991231 F1420 Cocaine dependence, uncomplicated 20151001 22991231 F1421 Cocaine dependence, in remission 20151001 22991231 F14220 Cocaine dependence with intoxication, uncomplicated 20151001 22991231 F14221 Cocaine dependence with intoxication delirium 20151001 22991231 F14222 Cocaine dependence w intoxication w perceptual disturbance 20151001 22991231 F14229 Cocaine dependence with intoxication, unspecified 20151001 22991231 F1423 Cocaine dependence with withdrawal 20151001 22991231 F1424 Cocaine dependence with cocaine-induced mood disorder 20151001 22991231 F14250 Cocaine depend w cocaine-induc psych disorder w delusions 20151001 22991231 F14251 Cocaine depend w cocaine-induc psychotic disorder w hallucin 20151001 22991231 F14259 Cocaine dependence w cocaine-induc psychotic disorder, unsp 20151001 22991231 F14280 Cocaine dependence with cocaine-induced anxiety disorder 20151001 22991231 F14281 Cocaine dependence with cocaine-induced sexual dysfunction 20151001 22991231 F14282 Cocaine dependence with cocaine-induced sleep disorder 20151001 22991231 F14288 Cocaine dependence with other cocaine-induced disorder 20151001 22991231 F1429 Cocaine dependence with unspecified cocaine-induced disorder 20151001 22991231 F1490 Cocaine use, unspecified, uncomplicated 20151001 22991231 F14920 Cocaine use, unspecified with intoxication, uncomplicated 20151001 22991231 F14921 Cocaine use, unspecified with intoxication delirium 20151001 22991231 F14922 Cocaine use, unsp w intoxication with perceptual disturbance 20151001 22991231 F14929 Cocaine use, unspecified with intoxication, unspecified 20151001 22991231 F1493 Cocaine use, unspecified with withdrawal 20201001 22991231 F1494 Cocaine use, unspecified with cocaine-induced mood disorder 20151001 22991231 F14950 Cocaine use, unsp w cocaine-induc psych disorder w delusions 20151001 22991231 F14951 Cocaine use, unsp w cocaine-induc psych disorder w hallucin 20151001 22991231 F14959 Cocaine use, unsp w cocaine-induced psychotic disorder, unsp 20151001 22991231 F14980 Cocaine use, unsp with cocaine-induced anxiety disorder 20151001 22991231
126 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F14981 Cocaine use, unsp with cocaine-induced sexual dysfunction 20151001 22991231 F14982 Cocaine use, unspecified with cocaine-induced sleep disorder 20151001 22991231 F14988 Cocaine use, unspecified with other cocaine-induced disorder 20151001 22991231 F1499 Cocaine use, unsp with unspecified cocaine-induced disorder 20151001 22991231 F1510 Other stimulant abuse, uncomplicated 20151001 22991231 F1511 Other stimulant abuse, in remission 20171001 22991231 F15120 Other stimulant abuse with intoxication, uncomplicated 20151001 22991231 F15121 Other stimulant abuse with intoxication delirium 20151001 22991231 F15122 Oth stimulant abuse w intoxication w perceptual disturbance 20151001 22991231 F15129 Other stimulant abuse with intoxication, unspecified 20151001 22991231 F1513 Other stimulant abuse with withdrawal 20201001 22991231 F1514 Other stimulant abuse with stimulant-induced mood disorder 20151001 22991231 F15150 Oth stimulant abuse w stim-induce psych disorder w delusions 20151001 22991231 F15151 Oth stimulant abuse w stim-induce psych disorder w hallucin 20151001 22991231 F15159 Oth stimulant abuse w stim-induce psychotic disorder, unsp 20151001 22991231 F15180 Oth stimulant abuse with stimulant-induced anxiety disorder 20151001 22991231 F15181 Oth stimulant abuse w stimulant-induced sexual dysfunction 20151001 22991231 F15182 Other stimulant abuse with stimulant-induced sleep disorder 20151001 22991231 F15188 Other stimulant abuse with other stimulant-induced disorder 20151001 22991231 F1519 Other stimulant abuse with unsp stimulant-induced disorder 20151001 22991231 F1520 Other stimulant dependence, uncomplicated 20151001 22991231 F1521 Other stimulant dependence, in remission 20151001 22991231 F15220 Other stimulant dependence with intoxication, uncomplicated 20151001 22991231 F15221 Other stimulant dependence with intoxication delirium 20151001 22991231 F15222 Oth stimulant dependence w intox w perceptual disturbance 20151001 22991231 F15229 Other stimulant dependence with intoxication, unspecified 20151001 22991231 F1523 Other stimulant dependence with withdrawal 20151001 22991231 F1524 Oth stimulant dependence w stimulant-induced mood disorder 20151001 22991231 F15250 Oth stim depend w stim-induce psych disorder w delusions 20151001 22991231 F15251 Oth stimulant depend w stim-induce psych disorder w hallucin 20151001 22991231 F15259 Oth stimulant depend w stim-induce psychotic disorder, unsp 20151001 22991231 F15280 Oth stimulant dependence w stim-induce anxiety disorder 20151001 22991231
127 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F15281 Oth stimulant dependence w stim-induce sexual dysfunction 20151001 22991231 F15282 Oth stimulant dependence w stimulant-induced sleep disorder 20151001 22991231 F15288 Oth stimulant dependence with oth stimulant-induced disorder 20151001 22991231 F1529 Oth stimulant dependence w unsp stimulant-induced disorder 20151001 22991231 F1590 Other stimulant use, unspecified, uncomplicated 20151001 22991231 F15920 Other stimulant use, unsp with intoxication, uncomplicated 20151001 22991231 F15921 Other stimulant use, unspecified with intoxication delirium 20151001 22991231 F15922 Oth stimulant use, unsp w intox w perceptual disturbance 20151001 22991231 F15929 Other stimulant use, unsp with intoxication, unspecified 20151001 22991231 F1593 Other stimulant use, unspecified with withdrawal 20151001 22991231 F1594 Oth stimulant use, unsp with stimulant-induced mood disorder 20151001 22991231 F15950 Oth stim use, unsp w stim-induce psych disorder w delusions 20151001 22991231 F15951 Oth stim use, unsp w stim-induce psych disorder w hallucin 20151001 22991231 F15959 Oth stimulant use, unsp w stim-induce psych disorder, unsp 20151001 22991231 F15980 Oth stimulant use, unsp w stimulant-induced anxiety disorder 20151001 22991231 F15981 Oth stimulant use, unsp w stim-induce sexual dysfunction 20151001 22991231 F15982 Oth stimulant use, unsp w stimulant-induced sleep disorder 20151001 22991231 F15988 Oth stimulant use, unsp with oth stimulant-induced disorder 20151001 22991231 F1599 Oth stimulant use, unsp with unsp stimulant-induced disorder 20151001 22991231 F1610 Hallucinogen abuse, uncomplicated 20151001 22991231 F1611 Hallucinogen abuse, in remission 20171001 22991231 F16120 Hallucinogen abuse with intoxication, uncomplicated 20151001 22991231 F16121 Hallucinogen abuse with intoxication with delirium 20151001 22991231 F16122 Hallucinogen abuse w intoxication w perceptual disturbance 20151001 22991231 F16129 Hallucinogen abuse with intoxication, unspecified 20151001 22991231 F1614 Hallucinogen abuse with hallucinogen-induced mood disorder 20151001 22991231 F16150 Hallucinogen abuse w psychotic disorder w delusions 20151001 22991231 F16151 Hallucinogen abuse w psychotic disorder w hallucinations 20151001 22991231 F16159 Hallucinogen abuse w psychotic disorder, unsp 20151001 22991231 F16180 Hallucinogen abuse w hallucinogen-induced anxiety disorder 20151001 22991231 F16183 Hallucign abuse w hallucign persisting perception disorder 20151001 22991231 F16188 Hallucinogen abuse with other hallucinogen-induced disorder 20151001 22991231
128 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F1619 Hallucinogen abuse with unsp hallucinogen-induced disorder 20151001 22991231 F1620 Hallucinogen dependence, uncomplicated 20151001 22991231 F1621 Hallucinogen dependence, in remission 20151001 22991231 F16220 Hallucinogen dependence with intoxication, uncomplicated 20151001 22991231 F16221 Hallucinogen dependence with intoxication with delirium 20151001 22991231 F16229 Hallucinogen dependence with intoxication, unspecified 20151001 22991231 F1624 Hallucinogen dependence w hallucinogen-induced mood disorder 20151001 22991231 F16250 Hallucinogen dependence w psychotic disorder w delusions 20151001 22991231 F16251 Hallucinogen dependence w psychotic disorder w hallucin 20151001 22991231 F16259 Hallucinogen dependence w psychotic disorder, unsp 20151001 22991231 F16280 Hallucinogen dependence w anxiety disorder 20151001 22991231 F16283 Hallucign depend w hallucign persisting perception disorder 20151001 22991231 F16288 Hallucinogen dependence w oth hallucinogen-induced disorder 20151001 22991231 F1629 Hallucinogen dependence w unsp hallucinogen-induced disorder 20151001 22991231 F1690 Hallucinogen use, unspecified, uncomplicated 20151001 22991231 F16920 Hallucinogen use, unsp with intoxication, uncomplicated 20151001 22991231 F16921 Hallucinogen use, unsp with intoxication with delirium 20151001 22991231 F16929 Hallucinogen use, unspecified with intoxication, unspecified 20151001 22991231 F1694 Hallucinogen use, unsp w hallucinogen-induced mood disorder 20151001 22991231 F16950 Hallucinogen use, unsp w psychotic disorder w delusions 20151001 22991231 F16951 Hallucinogen use, unsp w psychotic disorder w hallucinations 20151001 22991231 F16959 Hallucinogen use, unsp w psychotic disorder, unsp 20151001 22991231 F16980 Hallucinogen use, unsp w anxiety disorder 20151001 22991231 F16983 Hallucign use, unsp w hallucign persist perception disorder 20151001 22991231 F16988 Hallucinogen use, unsp w oth hallucinogen-induced disorder 20151001 22991231 F1699 Hallucinogen use, unsp w unsp hallucinogen-induced disorder 20151001 22991231 F17200 Nicotine dependence, unspecified, uncomplicated 20151001 22991231 F17201 Nicotine dependence, unspecified, in remission 20151001 22991231 F17203 Nicotine dependence unspecified, with withdrawal 20151001 22991231 F17208 Nicotine dependence, unsp, w oth nicotine-induced disorders 20151001 22991231 F17209 Nicotine dependence, unsp, w unsp nicotine-induced disorders 20151001 22991231 F17210 Nicotine dependence, cigarettes, uncomplicated 20151001 22991231
129 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F17211 Nicotine dependence, cigarettes, in remission 20151001 22991231 F17213 Nicotine dependence, cigarettes, with withdrawal 20151001 22991231 F17218 Nicotine dependence, cigarettes, w oth disorders 20151001 22991231 F17219 Nicotine dependence, cigarettes, w unsp disorders 20151001 22991231 F17220 Nicotine dependence, chewing tobacco, uncomplicated 20151001 22991231 F17221 Nicotine dependence, chewing tobacco, in remission 20151001 22991231 F17223 Nicotine dependence, chewing tobacco, with withdrawal 20151001 22991231 F17228 Nicotine dependence, chewing tobacco, w oth disorders 20151001 22991231 F17229 Nicotine dependence, chewing tobacco, w unsp disorders 20151001 22991231 F17290 Nicotine dependence, other tobacco product, uncomplicated 20151001 22991231 F17291 Nicotine dependence, other tobacco product, in remission 20151001 22991231 F17293 Nicotine dependence, other tobacco product, with withdrawal 20151001 22991231 F17298 Nicotine dependence, oth tobacco product, w oth disorders 20151001 22991231 F17299 Nicotine dependence, oth tobacco product, w unsp disorders 20151001 22991231 F1810 Inhalant abuse, uncomplicated 20151001 22991231 F1811 Inhalant abuse, in remission 20171001 22991231 F18120 Inhalant abuse with intoxication, uncomplicated 20151001 22991231 F18121 Inhalant abuse with intoxication delirium 20151001 22991231 F18129 Inhalant abuse with intoxication, unspecified 20151001 22991231 F1814 Inhalant abuse with inhalant-induced mood disorder 20151001 22991231 F18150 Inhalant abuse w inhalnt-induce psych disorder w delusions 20151001 22991231 F18151 Inhalant abuse w inhalnt-induce psych disorder w hallucin 20151001 22991231 F18159 Inhalant abuse w inhalant-induced psychotic disorder, unsp 20151001 22991231 F1817 Inhalant abuse with inhalant-induced dementia 20151001 22991231 F18180 Inhalant abuse with inhalant-induced anxiety disorder 20151001 22991231 F18188 Inhalant abuse with other inhalant-induced disorder 20151001 22991231 F1819 Inhalant abuse with unspecified inhalant-induced disorder 20151001 22991231 F1820 Inhalant dependence, uncomplicated 20151001 22991231 F1821 Inhalant dependence, in remission 20151001 22991231 F18220 Inhalant dependence with intoxication, uncomplicated 20151001 22991231 F18221 Inhalant dependence with intoxication delirium 20151001 22991231 F18229 Inhalant dependence with intoxication, unspecified 20151001 22991231
130 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F1824 Inhalant dependence with inhalant-induced mood disorder 20151001 22991231 F18250 Inhalant depend w inhalnt-induce psych disorder w delusions 20151001 22991231 F18251 Inhalant depend w inhalnt-induce psych disorder w hallucin 20151001 22991231 F18259 Inhalant depend w inhalnt-induce psychotic disorder, unsp 20151001 22991231 F1827 Inhalant dependence with inhalant-induced dementia 20151001 22991231 F18280 Inhalant dependence with inhalant-induced anxiety disorder 20151001 22991231 F18288 Inhalant dependence with other inhalant-induced disorder 20151001 22991231 F1829 Inhalant dependence with unsp inhalant-induced disorder 20151001 22991231 F1890 Inhalant use, unspecified, uncomplicated 20151001 22991231 F18920 Inhalant use, unspecified with intoxication, uncomplicated 20151001 22991231 F18921 Inhalant use, unspecified with intoxication with delirium 20151001 22991231 F18929 Inhalant use, unspecified with intoxication, unspecified 20151001 22991231 F1894 Inhalant use, unsp with inhalant-induced mood disorder 20151001 22991231 F18950 Inhalant use, unsp w inhalnt-induce psych disord w delusions 20151001 22991231 F18951 Inhalant use, unsp w inhalnt-induce psych disord w hallucin 20151001 22991231 F18959 Inhalant use, unsp w inhalnt-induce psychotic disorder, unsp 20151001 22991231 F1897 Inhalant use, unsp with inhalant-induced persisting dementia 20151001 22991231 F18980 Inhalant use, unsp with inhalant-induced anxiety disorder 20151001 22991231 F18988 Inhalant use, unsp with other inhalant-induced disorder 20151001 22991231 F1899 Inhalant use, unsp with unsp inhalant-induced disorder 20151001 22991231 F1910 Other psychoactive substance abuse, uncomplicated 20151001 22991231 F1911 Other psychoactive substance abuse, in remission 20171001 22991231 F19120 Oth psychoactive substance abuse w intoxication, uncomp 20151001 22991231 F19121 Oth psychoactive substance abuse with intoxication delirium 20151001 22991231 F19122 Oth psychoactv substance abuse w intox w perceptual disturb 20151001 22991231 F19129 Other psychoactive substance abuse with intoxication, unsp 20151001 22991231 F19130 Other psychoactive substance abuse with withdrawal, uncomp 20201001 22991231 F19131 Other psychoactive substance abuse with withdrawal delirium 20201001 22991231 F19132 Other psychoactv sub abuse with w/drawal w perceptl disturb 20201001 22991231 F19139 Other psychoactv substance abuse with withdrawal, unsp 20201001 22991231 F1914 Oth psychoactive substance abuse w mood disorder 20151001 22991231 F19150 Oth psychoactv substance abuse w psych disorder w delusions 20151001 22991231
131 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F19151 Oth psychoactv substance abuse w psych disorder w hallucin 20151001 22991231 F19159 Oth psychoactive substance abuse w psychotic disorder, unsp 20151001 22991231 F1916 Oth psychoactv substance abuse w persist amnestic disorder 20151001 22991231 F1917 Oth psychoactive substance abuse w persisting dementia 20151001 22991231 F19180 Oth psychoactive substance abuse w anxiety disorder 20151001 22991231 F19181 Oth psychoactive substance abuse w sexual dysfunction 20151001 22991231 F19182 Oth psychoactive substance abuse w sleep disorder 20151001 22991231 F19188 Oth psychoactive substance abuse w oth disorder 20151001 22991231 F1919 Oth psychoactive substance abuse w unsp disorder 20151001 22991231 F1920 Other psychoactive substance dependence, uncomplicated 20151001 22991231 F1921 Other psychoactive substance dependence, in remission 20151001 22991231 F19220 Oth psychoactive substance dependence w intoxication, uncomp 20151001 22991231 F19221 Oth psychoactive substance dependence w intox delirium 20151001 22991231 F19222 Oth psychoactv substance depend w intox w perceptual disturb 20151001 22991231 F19229 Oth psychoactive substance dependence w intoxication, unsp 20151001 22991231 F19230 Oth psychoactive substance dependence w withdrawal, uncomp 20151001 22991231 F19231 Oth psychoactive substance dependence w withdrawal delirium 20151001 22991231 F19232 Oth psychoactv sub depend w w/drawal w perceptl disturb 20151001 22991231 F19239 Oth psychoactive substance dependence with withdrawal, unsp 20151001 22991231 F1924 Oth psychoactive substance dependence w mood disorder 20151001 22991231 F19250 Oth psychoactv substance depend w psych disorder w delusions 20151001 22991231 F19251 Oth psychoactv substance depend w psych disorder w hallucin 20151001 22991231 F19259 Oth psychoactv substance depend w psychotic disorder, unsp 20151001 22991231 F1926 Oth psychoactv substance depend w persist amnestic disorder 20151001 22991231 F1927 Oth psychoactive substance dependence w persisting dementia 20151001 22991231 F19280 Oth psychoactive substance dependence w anxiety disorder 20151001 22991231 F19281 Oth psychoactive substance dependence w sexual dysfunction 20151001 22991231 F19282 Oth psychoactive substance dependence w sleep disorder 20151001 22991231 F19288 Oth psychoactive substance dependence w oth disorder 20151001 22991231 F1929 Oth psychoactive substance dependence w unsp disorder 20151001 22991231 F1990 Other psychoactive substance use, unspecified, uncomplicated 20151001 22991231 F19920 Oth psychoactive substance use, unsp w intoxication, uncomp 20151001 22991231
132 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F19921 Oth psychoactive substance use, unsp w intox w delirium 20151001 22991231 F19922 Oth psychoactv sub use, unsp w intox w perceptl disturb 20151001 22991231 F19929 Oth psychoactive substance use, unsp with intoxication, unsp 20151001 22991231 F19930 Oth psychoactive substance use, unsp w withdrawal, uncomp 20151001 22991231 F19931 Oth psychoactive substance use, unsp w withdrawal delirium 20151001 22991231 F19932 Oth psychoactv sub use, unsp w w/drawal w perceptl disturb 20151001 22991231 F19939 Other psychoactive substance use, unsp with withdrawal, unsp 20151001 22991231 F1994 Oth psychoactive substance use, unsp w mood disorder 20151001 22991231 F19950 Oth psychoactv sub use, unsp w psych disorder w delusions 20151001 22991231 F19951 Oth psychoactv sub use, unsp w psych disorder w hallucin 20151001 22991231 F19959 Oth psychoactv substance use, unsp w psych disorder, unsp 20151001 22991231 F1996 Oth psychoactv sub use, unsp w persist amnestic disorder 20151001 22991231 F1997 Oth psychoactive substance use, unsp w persisting dementia 20151001 22991231 F19980 Oth psychoactive substance use, unsp w anxiety disorder 20151001 22991231 F19981 Oth psychoactive substance use, unsp w sexual dysfunction 20151001 22991231 F19982 Oth psychoactive substance use, unsp w sleep disorder 20151001 22991231 F19988 Oth psychoactive substance use, unsp w oth disorder 20151001 22991231 F1999 Oth psychoactive substance use, unsp w unsp disorder 20151001 22991231 F200 Paranoid schizophrenia 20151001 22991231 F201 Disorganized schizophrenia 20151001 22991231 F202 Catatonic schizophrenia 20151001 22991231 F203 Undifferentiated schizophrenia 20151001 22991231 F205 Residual schizophrenia 20151001 22991231 F2081 Schizophreniform disorder 20151001 22991231 F2089 Other schizophrenia 20151001 22991231 F209 Schizophrenia, unspecified 20151001 22991231 F21 Schizotypal disorder 20151001 22991231 F22 Delusional disorders 20151001 22991231 F23 Brief psychotic disorder 20151001 22991231 F24 Shared psychotic disorder 20151001 22991231 F250 Schizoaffective disorder, bipolar type 20151001 22991231 F251 Schizoaffective disorder, depressive type 20151001 22991231
133 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F258 Other schizoaffective disorders 20151001 22991231 F259 Schizoaffective disorder, unspecified 20151001 22991231 F28 Oth psych disorder not due to a sub or known physiol cond 20151001 22991231 F29 Unsp psychosis not due to a substance or known physiol cond 20151001 22991231 F3010 Manic episode without psychotic symptoms, unspecified 20151001 22991231 F3011 Manic episode without psychotic symptoms, mild 20151001 22991231 F3012 Manic episode without psychotic symptoms, moderate 20151001 22991231 F3013 Manic episode, severe, without psychotic symptoms 20151001 22991231 F302 Manic episode, severe with psychotic symptoms 20151001 22991231 F303 Manic episode in partial remission 20151001 22991231 F304 Manic episode in full remission 20151001 22991231 F308 Other manic episodes 20151001 22991231 F309 Manic episode, unspecified 20151001 22991231 F310 Bipolar disorder, current episode hypomanic 20151001 22991231 F3110 Bipolar disord, crnt episode manic w/o psych features, unsp 20151001 22991231 F3111 Bipolar disord, crnt episode manic w/o psych features, mild 20151001 22991231 F3112 Bipolar disord, crnt episode manic w/o psych features, mod 20151001 22991231 F3113 Bipolar disord, crnt epsd manic w/o psych features, severe 20151001 22991231 F312 Bipolar disord, crnt episode manic severe w psych features 20151001 22991231 F3130 Bipolar disord, crnt epsd depress, mild or mod severt, unsp 20151001 22991231 F3131 Bipolar disorder, current episode depressed, mild 20151001 22991231 F3132 Bipolar disorder, current episode depressed, moderate 20151001 22991231 F314 Bipolar disord, crnt epsd depress, sev, w/o psych features 20151001 22991231 F315 Bipolar disord, crnt epsd depress, severe, w psych features 20151001 22991231 F3160 Bipolar disorder, current episode mixed, unspecified 20151001 22991231 F3161 Bipolar disorder, current episode mixed, mild 20151001 22991231 F3162 Bipolar disorder, current episode mixed, moderate 20151001 22991231 F3163 Bipolar disord, crnt epsd mixed, severe, w/o psych features 20151001 22991231 F3164 Bipolar disord, crnt episode mixed, severe, w psych features 20151001 22991231 F3170 Bipolar disord, currently in remis, most recent episode unsp 20151001 22991231 F3171 Bipolar disord, in partial remis, most recent epsd hypomanic 20151001 22991231 F3172 Bipolar disord, in full remis, most recent episode hypomanic 20151001 22991231
134 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F3173 Bipolar disord, in partial remis, most recent episode manic 20151001 22991231 F3174 Bipolar disorder, in full remis, most recent episode manic 20151001 22991231 F3175 Bipolar disord, in partial remis, most recent epsd depress 20151001 22991231 F3176 Bipolar disorder, in full remis, most recent episode depress 20151001 22991231 F3177 Bipolar disord, in partial remis, most recent episode mixed 20151001 22991231 F3178 Bipolar disorder, in full remis, most recent episode mixed 20151001 22991231 F3181 Bipolar II disorder 20151001 22991231 F3189 Other bipolar disorder 20151001 22991231 F319 Bipolar disorder, unspecified 20151001 22991231 F320 Major depressive disorder, single episode, mild 20151001 22991231 F321 Major depressive disorder, single episode, moderate 20151001 22991231 F322 Major depressv disord, single epsd, sev w/o psych features 20151001 22991231 F323 Major depressv disord, single epsd, severe w psych features 20151001 22991231 F324 Major depressv disorder, single episode, in partial remis 20151001 22991231 F325 Major depressive disorder, single episode, in full remission 20151001 22991231 F328 Other depressive episodes 20151001 20160930 F3281 Premenstrual dysphoric disorder 20161001 22991231 F3289 Other specified depressive episodes 20161001 22991231 F329 Major depressive disorder, single episode, unspecified 20151001 22991231 F330 Major depressive disorder, recurrent, mild 20151001 22991231 F331 Major depressive disorder, recurrent, moderate 20151001 22991231 F332 Major depressv disorder, recurrent severe w/o psych features 20151001 22991231 F333 Major depressv disorder, recurrent, severe w psych symptoms 20151001 22991231 F3340 Major depressive disorder, recurrent, in remission, unsp 20151001 22991231 F3341 Major depressive disorder, recurrent, in partial remission 20151001 22991231 F3342 Major depressive disorder, recurrent, in full remission 20151001 22991231 F338 Other recurrent depressive disorders 20151001 22991231 F339 Major depressive disorder, recurrent, unspecified 20151001 22991231 F340 Cyclothymic disorder 20151001 22991231 F341 Dysthymic disorder 20151001 22991231 F348 Other persistent mood [affective] disorders 20151001 20160930 F3481 Disruptive mood dysregulation disorder 20161001 22991231
135 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F3489 Other specified persistent mood disorders 20161001 22991231 F349 Persistent mood [affective] disorder, unspecified 20151001 22991231 F39 Unspecified mood [affective] disorder 20151001 22991231 F4000 Agoraphobia, unspecified 20151001 22991231 F4001 Agoraphobia with panic disorder 20151001 22991231 F4002 Agoraphobia without panic disorder 20151001 22991231 F4010 Social phobia, unspecified 20151001 22991231 F4011 Social phobia, generalized 20151001 22991231 F40210 Arachnophobia 20151001 22991231 F40218 Other animal type phobia 20151001 22991231 F40220 Fear of thunderstorms 20151001 22991231 F40228 Other natural environment type phobia 20151001 22991231 F40230 Fear of blood 20151001 22991231 F40231 Fear of injections and transfusions 20151001 22991231 F40232 Fear of other medical care 20151001 22991231 F40233 Fear of injury 20151001 22991231 F40240 Claustrophobia 20151001 22991231 F40241 Acrophobia 20151001 22991231 F40242 Fear of bridges 20151001 22991231 F40243 Fear of flying 20151001 22991231 F40248 Other situational type phobia 20151001 22991231 F40290 Androphobia 20151001 22991231 F40291 Gynephobia 20151001 22991231 F40298 Other specified phobia 20151001 22991231 F408 Other phobic anxiety disorders 20151001 22991231 F409 Phobic anxiety disorder, unspecified 20151001 22991231 F410 Panic disorder [episodic paroxysmal anxiety] 20151001 22991231 F411 Generalized anxiety disorder 20151001 22991231 F413 Other mixed anxiety disorders 20151001 22991231 F418 Other specified anxiety disorders 20151001 22991231 F419 Anxiety disorder, unspecified 20151001 22991231 F42 Obsessive-compulsive disorder 20151001 20160930
136 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F422 Mixed obsessional thoughts and acts 20161001 22991231 F423 Hoarding disorder 20161001 22991231 F424 Excoriation (skin-picking) disorder 20161001 22991231 F428 Other obsessive-compulsive disorder 20161001 22991231 F429 Obsessive-compulsive disorder, unspecified 20161001 22991231 F430 Acute stress reaction 20151001 22991231 F4310 Post-traumatic stress disorder, unspecified 20151001 22991231 F4311 Post-traumatic stress disorder, acute 20151001 22991231 F4312 Post-traumatic stress disorder, chronic 20151001 22991231 F4320 Adjustment disorder, unspecified 20151001 22991231 F4321 Adjustment disorder with depressed mood 20151001 22991231 F4322 Adjustment disorder with anxiety 20151001 22991231 F4323 Adjustment disorder with mixed anxiety and depressed mood 20151001 22991231 F4324 Adjustment disorder with disturbance of conduct 20151001 22991231 F4325 Adjustment disorder w mixed disturb of emotions and conduct 20151001 22991231 F4329 Adjustment disorder with other symptoms 20151001 22991231 F438 Other reactions to severe stress 20151001 22991231 F439 Reaction to severe stress, unspecified 20151001 22991231 F440 Dissociative amnesia 20151001 22991231 F441 Dissociative fugue 20151001 22991231 F442 Dissociative stupor 20151001 22991231 F444 Conversion disorder with motor symptom or deficit 20151001 22991231 F445 Conversion disorder with seizures or convulsions 20151001 22991231 F446 Conversion disorder with sensory symptom or deficit 20151001 22991231 F447 Conversion disorder with mixed symptom presentation 20151001 22991231 F4481 Dissociative identity disorder 20151001 22991231 F4489 Other dissociative and conversion disorders 20151001 22991231 F449 Dissociative and conversion disorder, unspecified 20151001 22991231 F450 Somatization disorder 20151001 22991231 F451 Undifferentiated somatoform disorder 20151001 22991231 F4520 Hypochondriacal disorder, unspecified 20151001 22991231 F4521 Hypochondriasis 20151001 22991231
137 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F4522 Body dysmorphic disorder 20151001 22991231 F4529 Other hypochondriacal disorders 20151001 22991231 F4541 Pain disorder exclusively related to psychological factors 20151001 22991231 F4542 Pain disorder with related psychological factors 20151001 22991231 F458 Other somatoform disorders 20151001 22991231 F459 Somatoform disorder, unspecified 20151001 22991231 F481 Depersonalization-derealization syndrome 20151001 22991231 F482 Pseudobulbar affect 20151001 22991231 F488 Other specified nonpsychotic mental disorders 20151001 22991231 F5000 Anorexia nervosa, unspecified 20151001 22991231 F5001 Anorexia nervosa, restricting type 20151001 22991231 F5002 Anorexia nervosa, binge eating/purging type 20151001 22991231 F502 Bulimia nervosa 20151001 22991231 F508 Other eating disorders 20151001 20160930 F5081 Binge eating disorder 20161001 22991231 F5082 Avoidant/restrictive food intake disorder 20171001 22991231 F5089 Other specified eating disorder 20161001 22991231 F515 Nightmare disorder 20151001 22991231 F520 Hypoactive sexual desire disorder 20151001 22991231 F521 Sexual aversion disorder 20151001 22991231 F53 Puerperal psychosis 20151001 20180930 F530 Postpartum depression 20181001 22991231 F531 Puerperal psychosis 20181001 22991231 F54 Psych & behavrl factors assoc w disord or dis classd elswhr 20151001 22991231 F550 Abuse of antacids 20151001 22991231 F551 Abuse of herbal or folk remedies 20151001 22991231 F552 Abuse of laxatives 20151001 22991231 F553 Abuse of steroids or hormones 20151001 22991231 F554 Abuse of vitamins 20151001 22991231 F558 Abuse of other non-psychoactive substances 20151001 22991231 F59 Unsp behavrl synd assoc w physiol disturb and physcl factors 20151001 22991231 F600 Paranoid personality disorder 20151001 22991231
138 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F601 Schizoid personality disorder 20151001 22991231 F602 Antisocial personality disorder 20151001 22991231 F603 Borderline personality disorder 20151001 22991231 F604 Histrionic personality disorder 20151001 22991231 F605 Obsessive-compulsive personality disorder 20151001 22991231 F606 Avoidant personality disorder 20151001 22991231 F607 Dependent personality disorder 20151001 22991231 F6081 Narcissistic personality disorder 20151001 22991231 F6089 Other specific personality disorders 20151001 22991231 F609 Personality disorder, unspecified 20151001 22991231 F630 Pathological gambling 20151001 22991231 F631 Pyromania 20151001 22991231 F632 Kleptomania 20151001 22991231 F633 Trichotillomania 20151001 22991231 F6381 Intermittent explosive disorder 20151001 22991231 F6389 Other impulse disorders 20151001 22991231 F639 Impulse disorder, unspecified 20151001 22991231 F640 Transsexualism 20161001 22991231 F641 Dual role transvestism 20151001 22991231 F642 Gender identity disorder of childhood 20151001 22991231 F648 Other gender identity disorders 20151001 22991231 F649 Gender identity disorder, unspecified 20151001 22991231 F650 Fetishism 20151001 22991231 F651 Transvestic fetishism 20151001 22991231 F652 Exhibitionism 20151001 22991231 F653 Voyeurism 20151001 22991231 F654 Pedophilia 20151001 22991231 F6550 Sadomasochism, unspecified 20151001 22991231 F6551 Sexual masochism 20151001 22991231 F6552 Sexual sadism 20151001 22991231 F6581 Frotteurism 20151001 22991231 F6589 Other paraphilias 20151001 22991231
139 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F659 Paraphilia, unspecified 20151001 22991231 F6810 Factitious disorder imposed on self, unspecified 20151001 22991231 F6811 Factit disord imposed on self, with predom psych signs/symp 20151001 22991231 F6812 Factit disord impsd on self, with predom physcl signs/symp 20151001 22991231 F6813 Factit disord impsd on self,w comb psych & physcl signs/symp 20151001 22991231 F688 Other specified disorders of adult personality and behavior 20151001 22991231 F68A Factitious disorder imposed on another 20181001 22991231 F69 Unspecified disorder of adult personality and behavior 20151001 22991231 F79 Unspecified intellectual disabilities 20190101 22991231 F8082 Social pragmatic communication disorder 20161001 22991231 F840 Autistic disorder 20151001 22991231 F843 Other childhood disintegrative disorder 20151001 22991231 F845 Asperger's syndrome 20151001 22991231 F848 Other pervasive developmental disorders 20151001 22991231 F849 Pervasive developmental disorder, unspecified 20151001 22991231 F88 Other disorders of psychological development 20151001 22991231 F89 Unspecified disorder of psychological development 20151001 22991231 F900 Attn-defct hyperactivity disorder, predom inattentive type 20151001 22991231 F901 Attn-defct hyperactivity disorder, predom hyperactive type 20151001 22991231 F902 Attention-deficit hyperactivity disorder, combined type 20151001 22991231 F908 Attention-deficit hyperactivity disorder, other type 20151001 22991231 F910 Conduct disorder confined to family context 20151001 22991231 F911 Conduct disorder, childhood-onset type 20151001 22991231 F912 Conduct disorder, adolescent-onset type 20151001 22991231 F913 Oppositional defiant disorder 20151001 22991231 F918 Other conduct disorders 20151001 22991231 F919 Conduct disorder, unspecified 20151001 22991231 F930 Separation anxiety disorder of childhood 20151001 22991231 F938 Other childhood emotional disorders 20151001 22991231 F939 Childhood emotional disorder, unspecified 20151001 22991231 F940 Selective mutism 20151001 22991231 F941 Reactive attachment disorder of childhood 20151001 22991231
140 Table 10 ICD-10-CM BH Diagnosis Codes ICD-10- ICD-10-CM descriptions Effective End Date CM Date
codes F942 Disinhibited attachment disorder of childhood 20151001 22991231 F948 Other childhood disorders of social functioning 20151001 22991231 F949 Childhood disorder of social functioning, unspecified 20151001 22991231 F950 Transient tic disorder 20151001 22991231 F951 Chronic motor or vocal tic disorder 20151001 22991231 F985 Adult onset fluency disorder 20151001 22991231 F988 Oth behav/emotn disord w onset usly occur in chldhd and adol 20151001 22991231 R69 Illness, unspecified 20151001 22991231 T1491XA Suicide attempt, initial encounter 20171001 22991231 T1491XD Suicide attempt, subsequent encounter 20171001 22991231 T1491XS Suicide attempt, sequela 20171001 22991231
Table Listing, Previous Table 10, Next Table 11a, End of Document
Table 11: Lab Procedures 81220-81224 do not require PA for the following ICD-10-CM Pregnancy Diagnosis Codes
Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O0900 Suprvsn of preg w history of infertility, unsp trimester 10/1/2015 12/31/2299 O0901 Suprvsn of preg w history of infertility, first trimester 10/1/2015 12/31/2299 O0902 Suprvsn of preg w history of infertility, second trimester 10/1/2015 12/31/2299 O0903 Suprvsn of preg w history of infertility, third trimester 10/1/2015 12/31/2299 O0910 Suprvsn of preg with history of ectopic preg, unsp trimester 10/1/2015 12/31/2299 O0911 Suprvsn of preg with history of ectopic preg, first tri 10/1/2015 12/31/2299 O0912 Suprvsn of preg with history of ectopic preg, second tri 10/1/2015 12/31/2299 O0913 Suprvsn of preg with history of ectopic preg, third tri 10/1/2015 12/31/2299 O09211 Suprvsn of preg w history of pre-term labor, first trimester 10/1/2015 12/31/2299 O09212 Suprvsn of preg w history of pre-term labor, second tri 10/1/2015 12/31/2299 O09213 Suprvsn of preg w history of pre-term labor, third trimester 10/1/2015 12/31/2299 O09219 Suprvsn of preg w history of pre-term labor, unsp trimester 10/1/2015 12/31/2299
141 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O09291 Suprvsn of preg w poor reprodctv or obstet hx, first tri 10/1/2015 12/31/2299 O09292 Suprvsn of preg w poor reprodctv or obstet hx, second tri 10/1/2015 12/31/2299 O09293 Suprvsn of preg w poor reprodctv or obstet hx, third tri 10/1/2015 12/31/2299 O09299 Suprvsn of preg w poor reprodctv or obstet history, unsp tri 10/1/2015 12/31/2299 O0930 Suprvsn of preg w insufficient antenat care, unsp trimester 10/1/2015 12/31/2299 O0931 Suprvsn of preg w insufficient antenat care, first trimester 10/1/2015 12/31/2299 O0932 Suprvsn of preg w insufficient antenat care, second tri 10/1/2015 12/31/2299 O0933 Suprvsn of preg w insufficient antenat care, third trimester 10/1/2015 12/31/2299 O0940 Supervision of pregnancy w grand multiparity, unsp trimester 10/1/2015 12/31/2299 O0941 Suprvsn of pregnancy w grand multiparity, first trimester 10/1/2015 12/31/2299 O0942 Suprvsn of pregnancy w grand multiparity, second trimester 10/1/2015 12/31/2299 O0943 Suprvsn of pregnancy w grand multiparity, third trimester 10/1/2015 12/31/2299 O09511 Supervision of elderly primigravida, first trimester 10/1/2015 12/31/2299 O09512 Supervision of elderly primigravida, second trimester 10/1/2015 12/31/2299 O09513 Supervision of elderly primigravida, third trimester 10/1/2015 12/31/2299 O09519 Supervision of elderly primigravida, unspecified trimester 10/1/2015 12/31/2299 O09521 Supervision of elderly multigravida, first trimester 10/1/2015 12/31/2299 O09522 Supervision of elderly multigravida, second trimester 10/1/2015 12/31/2299 O09523 Supervision of elderly multigravida, third trimester 10/1/2015 12/31/2299 O09529 Supervision of elderly multigravida, unspecified trimester 10/1/2015 12/31/2299 O09611 Supervision of young primigravida, first trimester 10/1/2015 12/31/2299 O09612 Supervision of young primigravida, second trimester 10/1/2015 12/31/2299 O09613 Supervision of young primigravida, third trimester 10/1/2015 12/31/2299 O09619 Supervision of young primigravida, unspecified trimester 10/1/2015 12/31/2299 O09621 Supervision of young multigravida, first trimester 10/1/2015 12/31/2299 O09622 Supervision of young multigravida, second trimester 10/1/2015 12/31/2299 O09623 Supervision of young multigravida, third trimester 10/1/2015 12/31/2299 O09629 Supervision of young multigravida, unspecified trimester 10/1/2015 12/31/2299 O0970 Suprvsn of high risk preg due to social problems, unsp tri 10/1/2015 12/31/2299 O0971 Suprvsn of high risk preg due to social problems, first tri 10/1/2015 12/31/2299 O0972 Suprvsn of high risk preg due to social problems, second tri 10/1/2015 12/31/2299 O0973 Suprvsn of high risk preg due to social problems, third tri 10/1/2015 12/31/2299
142 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O09811 Suprvsn of preg rslt from assisted reprodctv tech, first tri 10/1/2015 12/31/2299 O09812 Suprvsn of preg rslt from assist reprodctv tech, second tri 10/1/2015 12/31/2299 O09813 Suprvsn of preg rslt from assisted reprodctv tech, third tri 10/1/2015 12/31/2299 O09819 Suprvsn of preg rslt from assisted reprodctv tech, unsp tri 10/1/2015 12/31/2299 O09821 Suprvsn of preg w hx of in utero proc dur prev preg, 1st tri 10/1/2015 12/31/2299 O09822 Suprvsn of preg w hx of in utero proc dur prev preg, 2nd tri 10/1/2015 12/31/2299 O09823 Suprvsn of preg w hx of in utero proc dur prev preg, 3rd tri 10/1/2015 12/31/2299 O09829 Suprvsn of preg w hx of in utero proc dur prev preg,unsp tri 10/1/2015 12/31/2299 O09891 Supervision of other high risk pregnancies, first trimester 10/1/2015 12/31/2299 O09892 Supervision of other high risk pregnancies, second trimester 10/1/2015 12/31/2299 O09893 Supervision of other high risk pregnancies, third trimester 10/1/2015 12/31/2299 O09899 Supervision of other high risk pregnancies, unsp trimester 10/1/2015 12/31/2299 O0990 Supervision of high risk pregnancy, unsp, unsp trimester 10/1/2015 12/31/2299 O0991 Supervision of high risk pregnancy, unsp, first trimester 10/1/2015 12/31/2299 O0992 Supervision of high risk pregnancy, unsp, second trimester 10/1/2015 12/31/2299 O0993 Supervision of high risk pregnancy, unsp, third trimester 10/1/2015 12/31/2299 O30001 Twin preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299 O30002 Twin preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30003 Twin preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30011 Twin pregnancy, monochorionic/monoamniotic, first trimester 10/1/2015 12/31/2299 O30012 Twin pregnancy, monochorionic/monoamniotic, second trimester 10/1/2015 12/31/2299 O30013 Twin pregnancy, monochorionic/monoamniotic, third trimester 10/1/2015 12/31/2299 O30031 Twin pregnancy, monochorionic/diamniotic, first trimester 10/1/2015 12/31/2299 O30032 Twin pregnancy, monochorionic/diamniotic, second trimester 10/1/2015 12/31/2299 O30033 Twin pregnancy, monochorionic/diamniotic, third trimester 10/1/2015 12/31/2299 O30041 Twin pregnancy, dichorionic/diamniotic, first trimester 10/1/2015 12/31/2299 O30042 Twin pregnancy, dichorionic/diamniotic, second trimester 10/1/2015 12/31/2299 O30043 Twin pregnancy, dichorionic/diamniotic, third trimester 10/1/2015 12/31/2299 O30091 Twin preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30092 Twin preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 10/1/2015 12/31/2299 O30093 Twin preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299 O30101 Triplet preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299
143 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O30102 Triplet preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30103 Triplet preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30111 Triplet preg w two or more monochorionic fetuses, first tri 10/1/2015 12/31/2299 O30112 Triplet preg w two or more monochorionic fetuses, second tri 10/1/2015 12/31/2299 O30113 Triplet preg w two or more monochorionic fetuses, third tri 10/1/2015 12/31/2299 O30121 Triplet preg w two or more monoamnio fetuses, first tri 10/1/2015 12/31/2299 O30122 Triplet preg w two or more monoamnio fetuses, second tri 10/1/2015 12/31/2299 O30123 Triplet preg w two or more monoamnio fetuses, third tri 10/1/2015 12/31/2299 O30191 Trp preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30192 Trp preg, unable to dtrm num plcnta & amnio sacs, second tri 10/1/2015 12/31/2299 O30193 Trp preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299 O30201 Quad preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299 O30202 Quad preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30203 Quad preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30211 Quad preg w two or more monochorionic fetuses, first tri 10/1/2015 12/31/2299 O30212 Quad preg w two or more monochorionic fetuses, second tri 10/1/2015 12/31/2299 O30213 Quad preg w two or more monochorionic fetuses, third tri 10/1/2015 12/31/2299 O30221 Quad preg w two or more monoamnio fetuses, first trimester 10/1/2015 12/31/2299 O30222 Quad preg w two or more monoamnio fetuses, second trimester 10/1/2015 12/31/2299 O30223 Quad preg w two or more monoamnio fetuses, third trimester 10/1/2015 12/31/2299 O30291 Quad preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30292 Quad preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 10/1/2015 12/31/2299 O30293 Quad preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299 O30801 Oth multiple gest, unsp num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30802 Oth multiple gest, unsp num plcnta & amnio sacs, second tri 10/1/2015 12/31/2299 O30803 Oth multiple gest, unsp num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299 O30811 Oth mult gest w two or more monochorionic fetuses, first tri 10/1/2015 12/31/2299 O30812 Oth mult gest w two or more monochorionic fetuses, 2nd tri 10/1/2015 12/31/2299 O30813 Oth mult gest w two or more monochorionic fetuses, third tri 10/1/2015 12/31/2299 O30821 Oth multiple gest w two or more monoamnio fetuses, first tri 10/1/2015 12/31/2299 O30822 Oth mult gest w two or more monoamnio fetuses, second tri 10/1/2015 12/31/2299 O30823 Oth multiple gest w two or more monoamnio fetuses, third tri 10/1/2015 12/31/2299
144 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O30891 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 1st tri 10/1/2015 12/31/2299 O30892 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 2nd tri 10/1/2015 12/31/2299 O30893 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 3rd tri 10/1/2015 12/31/2299 O3091 Multiple gestation, unspecified, first trimester 10/1/2015 12/31/2299 O3092 Multiple gestation, unspecified, second trimester 10/1/2015 12/31/2299 O3093 Multiple gestation, unspecified, third trimester 10/1/2015 12/31/2299 O3111X0 Cont preg aft spon abort of one fts or more, first tri, unsp 10/1/2015 12/31/2299 O3111X1 Cont preg aft spon abort of one fts or more, first tri, fts1 10/1/2015 12/31/2299 O3111X2 Cont preg aft spon abort of one fts or more, first tri, fts2 10/1/2015 12/31/2299 O3111X3 Cont preg aft spon abort of one fts or more, first tri, fts3 10/1/2015 12/31/2299 O3111X4 Cont preg aft spon abort of one fts or more, first tri, fts4 10/1/2015 12/31/2299 O3111X5 Cont preg aft spon abort of one fts or more, first tri, fts5 10/1/2015 12/31/2299 O3111X9 Cont preg aft spon abort of one fts or more, first tri, oth 10/1/2015 12/31/2299 O3112X0 Cont preg aft spon abort of one fetus or more, 2nd tri, unsp 10/1/2015 12/31/2299 O3112X1 Cont preg aft spon abort of one fetus or more, 2nd tri, fts1 10/1/2015 12/31/2299 O3112X2 Cont preg aft spon abort of one fetus or more, 2nd tri, fts2 10/1/2015 12/31/2299 O3112X3 Cont preg aft spon abort of one fetus or more, 2nd tri, fts3 10/1/2015 12/31/2299 O3112X4 Cont preg aft spon abort of one fetus or more, 2nd tri, fts4 10/1/2015 12/31/2299 O3112X5 Cont preg aft spon abort of one fetus or more, 2nd tri, fts5 10/1/2015 12/31/2299 O3112X9 Cont preg aft spon abort of one fetus or more, 2nd tri, oth 10/1/2015 12/31/2299 O3113X0 Cont preg aft spon abort of one fts or more, third tri, unsp 10/1/2015 12/31/2299 O3113X1 Cont preg aft spon abort of one fts or more, third tri, fts1 10/1/2015 12/31/2299 O3113X2 Cont preg aft spon abort of one fts or more, third tri, fts2 10/1/2015 12/31/2299 O3113X3 Cont preg aft spon abort of one fts or more, third tri, fts3 10/1/2015 12/31/2299 O3113X4 Cont preg aft spon abort of one fts or more, third tri, fts4 10/1/2015 12/31/2299 O3113X5 Cont preg aft spon abort of one fts or more, third tri, fts5 10/1/2015 12/31/2299 O3113X9 Cont preg aft spon abort of one fts or more, third tri, oth 10/1/2015 12/31/2299 O3121X0 Cont preg aft uterin dth of one fts or more, first tri, unsp 10/1/2015 12/31/2299 O3121X1 Cont preg aft uterin dth of one fts or more, first tri, fts1 10/1/2015 12/31/2299 O3121X2 Cont preg aft uterin dth of one fts or more, first tri, fts2 10/1/2015 12/31/2299 O3121X3 Cont preg aft uterin dth of one fts or more, first tri, fts3 10/1/2015 12/31/2299 O3121X4 Cont preg aft uterin dth of one fts or more, first tri, fts4 10/1/2015 12/31/2299
145 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3121X5 Cont preg aft uterin dth of one fts or more, first tri, fts5 10/1/2015 12/31/2299 O3121X9 Cont preg aft uterin dth of one fts or more, first tri, oth 10/1/2015 12/31/2299 O3122X0 Cont preg aft uterin dth of one fetus or more, 2nd tri, unsp 10/1/2015 12/31/2299 O3122X1 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts1 10/1/2015 12/31/2299 O3122X2 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts2 10/1/2015 12/31/2299 O3122X3 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts3 10/1/2015 12/31/2299 O3122X4 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts4 10/1/2015 12/31/2299 O3122X5 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts5 10/1/2015 12/31/2299 O3122X9 Cont preg aft uterin dth of one fetus or more, 2nd tri, oth 10/1/2015 12/31/2299 O3123X0 Cont preg aft uterin dth of one fts or more, third tri, unsp 10/1/2015 12/31/2299 O3123X1 Cont preg aft uterin dth of one fts or more, third tri, fts1 10/1/2015 12/31/2299 O3123X2 Cont preg aft uterin dth of one fts or more, third tri, fts2 10/1/2015 12/31/2299 O3123X3 Cont preg aft uterin dth of one fts or more, third tri, fts3 10/1/2015 12/31/2299 O3123X4 Cont preg aft uterin dth of one fts or more, third tri, fts4 10/1/2015 12/31/2299 O3123X5 Cont preg aft uterin dth of one fts or more, third tri, fts5 10/1/2015 12/31/2299 O3123X9 Cont preg aft uterin dth of one fts or more, third tri, oth 10/1/2015 12/31/2299 O3131X0 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, unsp 10/1/2015 12/31/2299 O3131X1 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts1 10/1/2015 12/31/2299 O3131X2 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts2 10/1/2015 12/31/2299 O3131X3 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts3 10/1/2015 12/31/2299 O3131X4 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts4 10/1/2015 12/31/2299 O3131X5 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts5 10/1/2015 12/31/2299 O3131X9 Cont preg aft elctv fetl rdct of 1 fts or more, 1st tri, oth 10/1/2015 12/31/2299 O3132X0 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, unsp 10/1/2015 12/31/2299 O3132X1 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts1 10/1/2015 12/31/2299 O3132X2 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts2 10/1/2015 12/31/2299 O3132X3 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts3 10/1/2015 12/31/2299 O3132X4 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts4 10/1/2015 12/31/2299 O3132X5 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts5 10/1/2015 12/31/2299 O3132X9 Cont preg aft elctv fetl rdct of 1 fts or more, 2nd tri, oth 10/1/2015 12/31/2299 O3133X0 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, unsp 10/1/2015 12/31/2299 O3133X1 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts1 10/1/2015 12/31/2299
146 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3133X2 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts2 10/1/2015 12/31/2299 O3133X3 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts3 10/1/2015 12/31/2299 O3133X4 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts4 10/1/2015 12/31/2299 O3133X5 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts5 10/1/2015 12/31/2299 O3133X9 Cont preg aft elctv fetl rdct of 1 fts or more, 3rd tri, oth 10/1/2015 12/31/2299 O318X10 Oth comp specific to multiple gest, first trimester, unsp 10/1/2015 12/31/2299 O318X11 Oth comp specific to multiple gest, first trimester, fetus 1 10/1/2015 12/31/2299 O318X12 Oth comp specific to multiple gest, first trimester, fetus 2 10/1/2015 12/31/2299 O318X13 Oth comp specific to multiple gest, first trimester, fetus 3 10/1/2015 12/31/2299 O318X14 Oth comp specific to multiple gest, first trimester, fetus 4 10/1/2015 12/31/2299 O318X15 Oth comp specific to multiple gest, first trimester, fetus 5 10/1/2015 12/31/2299 O318X19 Oth comp specific to multiple gest, first trimester, oth 10/1/2015 12/31/2299 O318X20 Oth comp specific to multiple gest, second trimester, unsp 10/1/2015 12/31/2299 O318X21 Oth comp specific to multiple gest, second tri, fetus 1 10/1/2015 12/31/2299 O318X22 Oth comp specific to multiple gest, second tri, fetus 2 10/1/2015 12/31/2299 O318X23 Oth comp specific to multiple gest, second tri, fetus 3 10/1/2015 12/31/2299 O318X24 Oth comp specific to multiple gest, second tri, fetus 4 10/1/2015 12/31/2299 O318X25 Oth comp specific to multiple gest, second tri, fetus 5 10/1/2015 12/31/2299 O318X29 Oth comp specific to multiple gest, second trimester, oth 10/1/2015 12/31/2299 O318X30 Oth comp specific to multiple gest, third trimester, unsp 10/1/2015 12/31/2299 O318X31 Oth comp specific to multiple gest, third trimester, fetus 1 10/1/2015 12/31/2299 O318X32 Oth comp specific to multiple gest, third trimester, fetus 2 10/1/2015 12/31/2299 O318X33 Oth comp specific to multiple gest, third trimester, fetus 3 10/1/2015 12/31/2299 O318X34 Oth comp specific to multiple gest, third trimester, fetus 4 10/1/2015 12/31/2299 O318X35 Oth comp specific to multiple gest, third trimester, fetus 5 10/1/2015 12/31/2299 O318X39 Oth comp specific to multiple gest, third trimester, oth 10/1/2015 12/31/2299 O320XX0 Maternal care for unstable lie, not applicable or unsp 10/1/2015 12/31/2299 O320XX1 Maternal care for unstable lie, fetus 1 10/1/2015 12/31/2299 O320XX2 Maternal care for unstable lie, fetus 2 10/1/2015 12/31/2299 O320XX3 Maternal care for unstable lie, fetus 3 10/1/2015 12/31/2299 O320XX4 Maternal care for unstable lie, fetus 4 10/1/2015 12/31/2299 O320XX5 Maternal care for unstable lie, fetus 5 10/1/2015 12/31/2299
147 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O320XX9 Maternal care for unstable lie, other fetus 10/1/2015 12/31/2299 O321XX0 Maternal care for breech presentation, unsp 10/1/2015 12/31/2299 O321XX1 Maternal care for breech presentation, fetus 1 10/1/2015 12/31/2299 O321XX2 Maternal care for breech presentation, fetus 2 10/1/2015 12/31/2299 O321XX3 Maternal care for breech presentation, fetus 3 10/1/2015 12/31/2299 O321XX4 Maternal care for breech presentation, fetus 4 10/1/2015 12/31/2299 O321XX5 Maternal care for breech presentation, fetus 5 10/1/2015 12/31/2299 O321XX9 Maternal care for breech presentation, other fetus 10/1/2015 12/31/2299 O322XX0 Maternal care for transverse and oblique lie, unsp 10/1/2015 12/31/2299 O322XX1 Maternal care for transverse and oblique lie, fetus 1 10/1/2015 12/31/2299 O322XX2 Maternal care for transverse and oblique lie, fetus 2 10/1/2015 12/31/2299 O322XX3 Maternal care for transverse and oblique lie, fetus 3 10/1/2015 12/31/2299 O322XX4 Maternal care for transverse and oblique lie, fetus 4 10/1/2015 12/31/2299 O322XX5 Maternal care for transverse and oblique lie, fetus 5 10/1/2015 12/31/2299 O322XX9 Maternal care for transverse and oblique lie, other fetus 10/1/2015 12/31/2299 O323XX0 Maternal care for face, brow and chin presentation, unsp 10/1/2015 12/31/2299 O323XX1 Maternal care for face, brow and chin presentation, fetus 1 10/1/2015 12/31/2299 O323XX2 Maternal care for face, brow and chin presentation, fetus 2 10/1/2015 12/31/2299 O323XX3 Maternal care for face, brow and chin presentation, fetus 3 10/1/2015 12/31/2299 O323XX4 Maternal care for face, brow and chin presentation, fetus 4 10/1/2015 12/31/2299 O323XX5 Maternal care for face, brow and chin presentation, fetus 5 10/1/2015 12/31/2299 O323XX9 Maternal care for face, brow and chin presentation, oth 10/1/2015 12/31/2299 O324XX0 Maternal care for high head at term, not applicable or unsp 10/1/2015 12/31/2299 O324XX1 Maternal care for high head at term, fetus 1 10/1/2015 12/31/2299 O324XX2 Maternal care for high head at term, fetus 2 10/1/2015 12/31/2299 O324XX3 Maternal care for high head at term, fetus 3 10/1/2015 12/31/2299 O324XX4 Maternal care for high head at term, fetus 4 10/1/2015 12/31/2299 O324XX5 Maternal care for high head at term, fetus 5 10/1/2015 12/31/2299 O324XX9 Maternal care for high head at term, other fetus 10/1/2015 12/31/2299 O326XX0 Maternal care for compound presentation, unsp 10/1/2015 12/31/2299 O326XX1 Maternal care for compound presentation, fetus 1 10/1/2015 12/31/2299 O326XX2 Maternal care for compound presentation, fetus 2 10/1/2015 12/31/2299
148 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O326XX3 Maternal care for compound presentation, fetus 3 10/1/2015 12/31/2299 O326XX4 Maternal care for compound presentation, fetus 4 10/1/2015 12/31/2299 O326XX5 Maternal care for compound presentation, fetus 5 10/1/2015 12/31/2299 O326XX9 Maternal care for compound presentation, other fetus 10/1/2015 12/31/2299 O328XX0 Maternal care for oth malpresentation of fetus, unsp 10/1/2015 12/31/2299 O328XX1 Maternal care for other malpresentation of fetus, fetus 1 10/1/2015 12/31/2299 O328XX2 Maternal care for other malpresentation of fetus, fetus 2 10/1/2015 12/31/2299 O328XX3 Maternal care for other malpresentation of fetus, fetus 3 10/1/2015 12/31/2299 O328XX4 Maternal care for other malpresentation of fetus, fetus 4 10/1/2015 12/31/2299 O328XX5 Maternal care for other malpresentation of fetus, fetus 5 10/1/2015 12/31/2299 O328XX9 Maternal care for oth malpresentation of fetus, other fetus 10/1/2015 12/31/2299 O329XX0 Maternal care for malpresentation of fetus, unsp, unsp 10/1/2015 12/31/2299 O329XX1 Maternal care for malpresentation of fetus, unsp, fetus 1 10/1/2015 12/31/2299 O329XX2 Maternal care for malpresentation of fetus, unsp, fetus 2 10/1/2015 12/31/2299 O329XX3 Maternal care for malpresentation of fetus, unsp, fetus 3 10/1/2015 12/31/2299 O329XX4 Maternal care for malpresentation of fetus, unsp, fetus 4 10/1/2015 12/31/2299 O329XX5 Maternal care for malpresentation of fetus, unsp, fetus 5 10/1/2015 12/31/2299 O329XX9 Maternal care for malpresentation of fetus, unsp, oth fetus 10/1/2015 12/31/2299 O330 Matern care for disproprtn d/t deformity of matern pelv bone 10/1/2015 12/31/2299 O331 Matern care for disproprtn d/t generally contracted pelvis 10/1/2015 12/31/2299 O332 Maternal care for disproprtn due to inlet contrctn of pelvis 10/1/2015 12/31/2299 O333XX0 Matern care for disproprtn d/t outlet contrctn of pelv, unsp 10/1/2015 12/31/2299 O333XX1 Matern care for disproprtn d/t outlet contrctn of pelv, fts1 10/1/2015 12/31/2299 O333XX2 Matern care for disproprtn d/t outlet contrctn of pelv, fts2 10/1/2015 12/31/2299 O333XX3 Matern care for disproprtn d/t outlet contrctn of pelv, fts3 10/1/2015 12/31/2299 O333XX4 Matern care for disproprtn d/t outlet contrctn of pelv, fts4 10/1/2015 12/31/2299 O333XX5 Matern care for disproprtn d/t outlet contrctn of pelv, fts5 10/1/2015 12/31/2299 O333XX9 Matern care for disproprtn d/t outlet contrctn of pelv, oth 10/1/2015 12/31/2299 O334XX0 Matern care for disproprtn of mix matern & fetl origin, unsp 10/1/2015 12/31/2299 O334XX1 Matern care for disproprtn of mix matern & fetl origin, fts1 10/1/2015 12/31/2299 O334XX2 Matern care for disproprtn of mix matern & fetl origin, fts2 10/1/2015 12/31/2299 O334XX3 Matern care for disproprtn of mix matern & fetl origin, fts3 10/1/2015 12/31/2299
149 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O334XX4 Matern care for disproprtn of mix matern & fetl origin, fts4 10/1/2015 12/31/2299 O334XX5 Matern care for disproprtn of mix matern & fetl origin, fts5 10/1/2015 12/31/2299 O334XX9 Matern care for disproprtn of mix matern & fetl origin, oth 10/1/2015 12/31/2299 O335XX0 Matern care for disproprtn d/t unusually large fetus, unsp 10/1/2015 12/31/2299 O335XX1 Matern care for disproprtn d/t unusually large fetus, fts1 10/1/2015 12/31/2299 O335XX2 Matern care for disproprtn d/t unusually large fetus, fts2 10/1/2015 12/31/2299 O335XX3 Matern care for disproprtn d/t unusually large fetus, fts3 10/1/2015 12/31/2299 O335XX4 Matern care for disproprtn d/t unusually large fetus, fts4 10/1/2015 12/31/2299 O335XX5 Matern care for disproprtn d/t unusually large fetus, fts5 10/1/2015 12/31/2299 O335XX9 Matern care for disproprtn due to unusually large fetus, oth 10/1/2015 12/31/2299 O336XX0 Matern care for disproprtn due to hydrocephalic fetus, unsp 10/1/2015 12/31/2299 O336XX1 Matern care for disproprtn due to hydrocephalic fetus, fts1 10/1/2015 12/31/2299 O336XX2 Matern care for disproprtn due to hydrocephalic fetus, fts2 10/1/2015 12/31/2299 O336XX3 Matern care for disproprtn due to hydrocephalic fetus, fts3 10/1/2015 12/31/2299 O336XX4 Matern care for disproprtn due to hydrocephalic fetus, fts4 10/1/2015 12/31/2299 O336XX5 Matern care for disproprtn due to hydrocephalic fetus, fts5 10/1/2015 12/31/2299 O336XX9 Maternal care for disproprtn due to hydrocephalic fetus, oth 10/1/2015 12/31/2299 O337 Maternal care for disproportion due to oth fetal deformities 10/1/2015 9/30/2016 O337XX0 Maternal care for disproprtn due to other fetal deform, unsp 10/1/2016 12/31/2299 O337XX1 Matern care for disproprtn due to other fetal deform, fts1 10/1/2016 12/31/2299 O337XX2 Matern care for disproprtn due to other fetal deform, fts2 10/1/2016 12/31/2299 O337XX3 Matern care for disproprtn due to other fetal deform, fts3 10/1/2016 12/31/2299 O337XX4 Matern care for disproprtn due to other fetal deform, fts4 10/1/2016 12/31/2299 O337XX5 Matern care for disproprtn due to other fetal deform, fts5 10/1/2016 12/31/2299 O337XX9 Maternal care for disproprtn due to other fetal deform, oth 10/1/2016 12/31/2299 O338 Maternal care for disproportion of other origin 10/1/2015 12/31/2299 O339 Maternal care for disproportion, unspecified 10/1/2015 12/31/2299 O3401 Maternal care for unsp congen malform of uterus, first tri 10/1/2015 12/31/2299 O3402 Maternal care for unsp congen malform of uterus, second tri 10/1/2015 12/31/2299 O3403 Maternal care for unsp congen malform of uterus, third tri 10/1/2015 12/31/2299 O3411 Maternal care for benign tumor of corpus uteri, first tri 10/1/2015 12/31/2299 O3412 Maternal care for benign tumor of corpus uteri, second tri 10/1/2015 12/31/2299
150 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3413 Maternal care for benign tumor of corpus uteri, third tri 10/1/2015 12/31/2299 O3421 Maternal care for scar from previous cesarean delivery 10/1/2015 9/30/2016 O34211 Matern care for low transverse scar from prev cesarean del 10/1/2016 12/31/2299 O34212 Maternal care for vertical scar from previous cesarean del 10/1/2016 12/31/2299 O34219 Maternal care for unsp type scar from previous cesarean del 10/1/2016 12/31/2299 O3429 Maternal care due to uterine scar from oth previous surgery 10/1/2015 12/31/2299 O3431 Maternal care for cervical incompetence, first trimester 10/1/2015 12/31/2299 O3432 Maternal care for cervical incompetence, second trimester 10/1/2015 12/31/2299 O3433 Maternal care for cervical incompetence, third trimester 10/1/2015 12/31/2299 O3441 Maternal care for oth abnlt of cervix, first trimester 10/1/2015 12/31/2299 O3442 Maternal care for oth abnlt of cervix, second trimester 10/1/2015 12/31/2299 O3443 Maternal care for oth abnlt of cervix, third trimester 10/1/2015 12/31/2299 O34511 Maternal care for incarceration of gravid uterus, first tri 10/1/2015 12/31/2299 O34512 Maternal care for incarceration of gravid uterus, second tri 10/1/2015 12/31/2299 O34513 Maternal care for incarceration of gravid uterus, third tri 10/1/2015 12/31/2299 O34521 Maternal care for prolapse of gravid uterus, first trimester 10/1/2015 12/31/2299 O34522 Maternal care for prolapse of gravid uterus, second tri 10/1/2015 12/31/2299 O34523 Maternal care for prolapse of gravid uterus, third trimester 10/1/2015 12/31/2299 O34531 Maternal care for retroversion of gravid uterus, first tri 10/1/2015 12/31/2299 O34532 Maternal care for retroversion of gravid uterus, second tri 10/1/2015 12/31/2299 O34533 Maternal care for retroversion of gravid uterus, third tri 10/1/2015 12/31/2299 O34591 Maternal care for oth abnlt of gravid uterus, first tri 10/1/2015 12/31/2299 O34592 Maternal care for oth abnlt of gravid uterus, second tri 10/1/2015 12/31/2299 O34593 Maternal care for oth abnlt of gravid uterus, third tri 10/1/2015 12/31/2299 O3461 Maternal care for abnormality of vagina, first trimester 10/1/2015 12/31/2299 O3462 Maternal care for abnormality of vagina, second trimester 10/1/2015 12/31/2299 O3463 Maternal care for abnormality of vagina, third trimester 10/1/2015 12/31/2299 O3471 Maternal care for abnlt of vulva and perineum, first tri 10/1/2015 12/31/2299 O3472 Maternal care for abnlt of vulva and perineum, second tri 10/1/2015 12/31/2299 O3473 Maternal care for abnlt of vulva and perineum, third tri 10/1/2015 12/31/2299 O3481 Maternal care for oth abnlt of pelvic organs, first tri 10/1/2015 12/31/2299 O3482 Maternal care for oth abnlt of pelvic organs, second tri 10/1/2015 12/31/2299
151 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3483 Maternal care for oth abnlt of pelvic organs, third tri 10/1/2015 12/31/2299 O3491 Maternal care for abnlt of pelvic organ, unsp, first tri 10/1/2015 12/31/2299 O3492 Maternal care for abnlt of pelvic organ, unsp, second tri 10/1/2015 12/31/2299 O3493 Maternal care for abnlt of pelvic organ, unsp, third tri 10/1/2015 12/31/2299 O350XX0 Maternal care for (suspected) cnsl malform in fetus, unsp 10/1/2015 12/31/2299 O350XX1 Maternal care for (suspected) cnsl malform in fetus, fetus 1 10/1/2015 12/31/2299 O350XX2 Maternal care for (suspected) cnsl malform in fetus, fetus 2 10/1/2015 12/31/2299 O350XX3 Maternal care for (suspected) cnsl malform in fetus, fetus 3 10/1/2015 12/31/2299 O350XX4 Maternal care for (suspected) cnsl malform in fetus, fetus 4 10/1/2015 12/31/2299 O350XX5 Maternal care for (suspected) cnsl malform in fetus, fetus 5 10/1/2015 12/31/2299 O350XX9 Maternal care for (suspected) cnsl malform in fetus, oth 10/1/2015 12/31/2299 O351XX0 Maternal care for chromosomal abnormality in fetus, unsp 10/1/2015 12/31/2299 O351XX1 Maternal care for chromosomal abnormality in fetus, fetus 1 10/1/2015 12/31/2299 O351XX2 Maternal care for chromosomal abnormality in fetus, fetus 2 10/1/2015 12/31/2299 O351XX3 Maternal care for chromosomal abnormality in fetus, fetus 3 10/1/2015 12/31/2299 O351XX4 Maternal care for chromosomal abnormality in fetus, fetus 4 10/1/2015 12/31/2299 O351XX5 Maternal care for chromosomal abnormality in fetus, fetus 5 10/1/2015 12/31/2299 O351XX9 Maternal care for chromosomal abnormality in fetus, oth 10/1/2015 12/31/2299 O352XX0 Maternal care for hereditary disease in fetus, unsp 10/1/2015 12/31/2299 O352XX1 Maternal care for hereditary disease in fetus, fetus 1 10/1/2015 12/31/2299 O352XX2 Maternal care for hereditary disease in fetus, fetus 2 10/1/2015 12/31/2299 O352XX3 Maternal care for hereditary disease in fetus, fetus 3 10/1/2015 12/31/2299 O352XX4 Maternal care for hereditary disease in fetus, fetus 4 10/1/2015 12/31/2299 O352XX5 Maternal care for hereditary disease in fetus, fetus 5 10/1/2015 12/31/2299 O352XX9 Maternal care for hereditary disease in fetus, oth 10/1/2015 12/31/2299 O353XX0 Matern care for damag to fts from viral dis in mother, unsp 10/1/2015 12/31/2299 O353XX1 Matern care for damag to fts from viral dis in mother, fts1 10/1/2015 12/31/2299 O353XX2 Matern care for damag to fts from viral dis in mother, fts2 10/1/2015 12/31/2299 O353XX3 Matern care for damag to fts from viral dis in mother, fts3 10/1/2015 12/31/2299 O353XX4 Matern care for damag to fts from viral dis in mother, fts4 10/1/2015 12/31/2299 O353XX5 Matern care for damag to fts from viral dis in mother, fts5 10/1/2015 12/31/2299 O353XX9 Matern care for damag to fetus from viral dis in mother, oth 10/1/2015 12/31/2299
152 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O354XX0 Maternal care for damage to fetus from alcohol, unsp 10/1/2015 12/31/2299 O354XX1 Maternal care for damage to fetus from alcohol, fetus 1 10/1/2015 12/31/2299 O354XX2 Maternal care for damage to fetus from alcohol, fetus 2 10/1/2015 12/31/2299 O354XX3 Maternal care for damage to fetus from alcohol, fetus 3 10/1/2015 12/31/2299 O354XX4 Maternal care for damage to fetus from alcohol, fetus 4 10/1/2015 12/31/2299 O354XX5 Maternal care for damage to fetus from alcohol, fetus 5 10/1/2015 12/31/2299 O354XX9 Maternal care for damage to fetus from alcohol, oth 10/1/2015 12/31/2299 O355XX0 Maternal care for (suspected) damage to fetus by drugs, unsp 10/1/2015 12/31/2299 O355XX1 Maternal care for damage to fetus by drugs, fetus 1 10/1/2015 12/31/2299 O355XX2 Maternal care for damage to fetus by drugs, fetus 2 10/1/2015 12/31/2299 O355XX3 Maternal care for damage to fetus by drugs, fetus 3 10/1/2015 12/31/2299 O355XX4 Maternal care for damage to fetus by drugs, fetus 4 10/1/2015 12/31/2299 O355XX5 Maternal care for damage to fetus by drugs, fetus 5 10/1/2015 12/31/2299 O355XX9 Maternal care for (suspected) damage to fetus by drugs, oth 10/1/2015 12/31/2299 O356XX0 Maternal care for damage to fetus by radiation, unsp 10/1/2015 12/31/2299 O356XX1 Maternal care for damage to fetus by radiation, fetus 1 10/1/2015 12/31/2299 O356XX2 Maternal care for damage to fetus by radiation, fetus 2 10/1/2015 12/31/2299 O356XX3 Maternal care for damage to fetus by radiation, fetus 3 10/1/2015 12/31/2299 O356XX4 Maternal care for damage to fetus by radiation, fetus 4 10/1/2015 12/31/2299 O356XX5 Maternal care for damage to fetus by radiation, fetus 5 10/1/2015 12/31/2299 O356XX9 Maternal care for damage to fetus by radiation, oth 10/1/2015 12/31/2299 O358XX0 Maternal care for oth fetal abnormality and damage, unsp 10/1/2015 12/31/2299 O358XX1 Maternal care for oth fetal abnormality and damage, fetus 1 10/1/2015 12/31/2299 O358XX2 Maternal care for oth fetal abnormality and damage, fetus 2 10/1/2015 12/31/2299 O358XX3 Maternal care for oth fetal abnormality and damage, fetus 3 10/1/2015 12/31/2299 O358XX4 Maternal care for oth fetal abnormality and damage, fetus 4 10/1/2015 12/31/2299 O358XX5 Maternal care for oth fetal abnormality and damage, fetus 5 10/1/2015 12/31/2299 O358XX9 Maternal care for oth fetal abnormality and damage, oth 10/1/2015 12/31/2299 O359XX0 Maternal care for fetal abnormality and damage, unsp, unsp 10/1/2015 12/31/2299 O359XX1 Maternal care for fetal abnlt and damage, unsp, fetus 1 10/1/2015 12/31/2299 O359XX2 Maternal care for fetal abnlt and damage, unsp, fetus 2 10/1/2015 12/31/2299 O359XX3 Maternal care for fetal abnlt and damage, unsp, fetus 3 10/1/2015 12/31/2299
153 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O359XX4 Maternal care for fetal abnlt and damage, unsp, fetus 4 10/1/2015 12/31/2299 O359XX5 Maternal care for fetal abnlt and damage, unsp, fetus 5 10/1/2015 12/31/2299 O359XX9 Maternal care for fetal abnormality and damage, unsp, oth 10/1/2015 12/31/2299 O360110 Maternal care for anti-D antibodies, first trimester, unsp 10/1/2015 12/31/2299 O360111 Maternal care for anti-D antibodies, first tri, fetus 1 10/1/2015 12/31/2299 O360112 Maternal care for anti-D antibodies, first tri, fetus 2 10/1/2015 12/31/2299 O360113 Maternal care for anti-D antibodies, first tri, fetus 3 10/1/2015 12/31/2299 O360114 Maternal care for anti-D antibodies, first tri, fetus 4 10/1/2015 12/31/2299 O360115 Maternal care for anti-D antibodies, first tri, fetus 5 10/1/2015 12/31/2299 O360119 Maternal care for anti-D antibodies, first trimester, oth 10/1/2015 12/31/2299 O360120 Maternal care for anti-D antibodies, second trimester, unsp 10/1/2015 12/31/2299 O360121 Maternal care for anti-D antibodies, second tri, fetus 1 10/1/2015 12/31/2299 O360122 Maternal care for anti-D antibodies, second tri, fetus 2 10/1/2015 12/31/2299 O360123 Maternal care for anti-D antibodies, second tri, fetus 3 10/1/2015 12/31/2299 O360124 Maternal care for anti-D antibodies, second tri, fetus 4 10/1/2015 12/31/2299 O360125 Maternal care for anti-D antibodies, second tri, fetus 5 10/1/2015 12/31/2299 O360129 Maternal care for anti-D antibodies, second trimester, oth 10/1/2015 12/31/2299 O360130 Maternal care for anti-D antibodies, third trimester, unsp 10/1/2015 12/31/2299 O360131 Maternal care for anti-D antibodies, third tri, fetus 1 10/1/2015 12/31/2299 O360132 Maternal care for anti-D antibodies, third tri, fetus 2 10/1/2015 12/31/2299 O360133 Maternal care for anti-D antibodies, third tri, fetus 3 10/1/2015 12/31/2299 O360134 Maternal care for anti-D antibodies, third tri, fetus 4 10/1/2015 12/31/2299 O360135 Maternal care for anti-D antibodies, third tri, fetus 5 10/1/2015 12/31/2299 O360139 Maternal care for anti-D antibodies, third trimester, oth 10/1/2015 12/31/2299 O360910 Maternal care for oth rhesus isoimmun, first trimester, unsp 10/1/2015 12/31/2299 O360911 Maternal care for oth rhesus isoimmun, first tri, fetus 1 10/1/2015 12/31/2299 O360912 Maternal care for oth rhesus isoimmun, first tri, fetus 2 10/1/2015 12/31/2299 O360913 Maternal care for oth rhesus isoimmun, first tri, fetus 3 10/1/2015 12/31/2299 O360914 Maternal care for oth rhesus isoimmun, first tri, fetus 4 10/1/2015 12/31/2299 O360915 Maternal care for oth rhesus isoimmun, first tri, fetus 5 10/1/2015 12/31/2299 O360919 Maternal care for oth rhesus isoimmun, first trimester, oth 10/1/2015 12/31/2299 O360920 Maternal care for oth rhesus isoimmun, second tri, unsp 10/1/2015 12/31/2299
154 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O360921 Maternal care for oth rhesus isoimmun, second tri, fetus 1 10/1/2015 12/31/2299 O360922 Maternal care for oth rhesus isoimmun, second tri, fetus 2 10/1/2015 12/31/2299 O360923 Maternal care for oth rhesus isoimmun, second tri, fetus 3 10/1/2015 12/31/2299 O360924 Maternal care for oth rhesus isoimmun, second tri, fetus 4 10/1/2015 12/31/2299 O360925 Maternal care for oth rhesus isoimmun, second tri, fetus 5 10/1/2015 12/31/2299 O360929 Maternal care for oth rhesus isoimmun, second trimester, oth 10/1/2015 12/31/2299 O360930 Maternal care for oth rhesus isoimmun, third trimester, unsp 10/1/2015 12/31/2299 O360931 Maternal care for oth rhesus isoimmun, third tri, fetus 1 10/1/2015 12/31/2299 O360932 Maternal care for oth rhesus isoimmun, third tri, fetus 2 10/1/2015 12/31/2299 O360933 Maternal care for oth rhesus isoimmun, third tri, fetus 3 10/1/2015 12/31/2299 O360934 Maternal care for oth rhesus isoimmun, third tri, fetus 4 10/1/2015 12/31/2299 O360935 Maternal care for oth rhesus isoimmun, third tri, fetus 5 10/1/2015 12/31/2299 O360939 Maternal care for oth rhesus isoimmun, third trimester, oth 10/1/2015 12/31/2299 O361110 Maternal care for Anti-A sensitization, first tri, unsp 10/1/2015 12/31/2299 O361111 Maternal care for Anti-A sensitization, first tri, fetus 1 10/1/2015 12/31/2299 O361112 Maternal care for Anti-A sensitization, first tri, fetus 2 10/1/2015 12/31/2299 O361113 Maternal care for Anti-A sensitization, first tri, fetus 3 10/1/2015 12/31/2299 O361114 Maternal care for Anti-A sensitization, first tri, fetus 4 10/1/2015 12/31/2299 O361115 Maternal care for Anti-A sensitization, first tri, fetus 5 10/1/2015 12/31/2299 O361119 Maternal care for Anti-A sensitization, first trimester, oth 10/1/2015 12/31/2299 O361120 Maternal care for Anti-A sensitization, second tri, unsp 10/1/2015 12/31/2299 O361121 Maternal care for Anti-A sensitization, second tri, fetus 1 10/1/2015 12/31/2299 O361122 Maternal care for Anti-A sensitization, second tri, fetus 2 10/1/2015 12/31/2299 O361123 Maternal care for Anti-A sensitization, second tri, fetus 3 10/1/2015 12/31/2299 O361124 Maternal care for Anti-A sensitization, second tri, fetus 4 10/1/2015 12/31/2299 O361125 Maternal care for Anti-A sensitization, second tri, fetus 5 10/1/2015 12/31/2299 O361129 Maternal care for Anti-A sensitization, second tri, oth 10/1/2015 12/31/2299 O361130 Maternal care for Anti-A sensitization, third tri, unsp 10/1/2015 12/31/2299 O361131 Maternal care for Anti-A sensitization, third tri, fetus 1 10/1/2015 12/31/2299 O361132 Maternal care for Anti-A sensitization, third tri, fetus 2 10/1/2015 12/31/2299 O361133 Maternal care for Anti-A sensitization, third tri, fetus 3 10/1/2015 12/31/2299 O361134 Maternal care for Anti-A sensitization, third tri, fetus 4 10/1/2015 12/31/2299
155 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O361135 Maternal care for Anti-A sensitization, third tri, fetus 5 10/1/2015 12/31/2299 O361139 Maternal care for Anti-A sensitization, third trimester, oth 10/1/2015 12/31/2299 O361910 Maternal care for oth isoimmunization, first trimester, unsp 10/1/2015 12/31/2299 O361911 Maternal care for oth isoimmun, first trimester, fetus 1 10/1/2015 12/31/2299 O361912 Maternal care for oth isoimmun, first trimester, fetus 2 10/1/2015 12/31/2299 O361913 Maternal care for oth isoimmun, first trimester, fetus 3 10/1/2015 12/31/2299 O361914 Maternal care for oth isoimmun, first trimester, fetus 4 10/1/2015 12/31/2299 O361915 Maternal care for oth isoimmun, first trimester, fetus 5 10/1/2015 12/31/2299 O361919 Maternal care for oth isoimmunization, first trimester, oth 10/1/2015 12/31/2299 O361920 Maternal care for oth isoimmun, second trimester, unsp 10/1/2015 12/31/2299 O361921 Maternal care for oth isoimmun, second trimester, fetus 1 10/1/2015 12/31/2299 O361922 Maternal care for oth isoimmun, second trimester, fetus 2 10/1/2015 12/31/2299 O361923 Maternal care for oth isoimmun, second trimester, fetus 3 10/1/2015 12/31/2299 O361924 Maternal care for oth isoimmun, second trimester, fetus 4 10/1/2015 12/31/2299 O361925 Maternal care for oth isoimmun, second trimester, fetus 5 10/1/2015 12/31/2299 O361929 Maternal care for oth isoimmunization, second trimester, oth 10/1/2015 12/31/2299 O361930 Maternal care for oth isoimmunization, third trimester, unsp 10/1/2015 12/31/2299 O361931 Maternal care for oth isoimmun, third trimester, fetus 1 10/1/2015 12/31/2299 O361932 Maternal care for oth isoimmun, third trimester, fetus 2 10/1/2015 12/31/2299 O361933 Maternal care for oth isoimmun, third trimester, fetus 3 10/1/2015 12/31/2299 O361934 Maternal care for oth isoimmun, third trimester, fetus 4 10/1/2015 12/31/2299 O361935 Maternal care for oth isoimmun, third trimester, fetus 5 10/1/2015 12/31/2299 O361939 Maternal care for oth isoimmunization, third trimester, oth 10/1/2015 12/31/2299 O3621X0 Maternal care for hydrops fetalis, first trimester, unsp 10/1/2015 12/31/2299 O3621X1 Maternal care for hydrops fetalis, first trimester, fetus 1 10/1/2015 12/31/2299 O3621X2 Maternal care for hydrops fetalis, first trimester, fetus 2 10/1/2015 12/31/2299 O3621X3 Maternal care for hydrops fetalis, first trimester, fetus 3 10/1/2015 12/31/2299 O3621X4 Maternal care for hydrops fetalis, first trimester, fetus 4 10/1/2015 12/31/2299 O3621X5 Maternal care for hydrops fetalis, first trimester, fetus 5 10/1/2015 12/31/2299 O3621X9 Maternal care for hydrops fetalis, first trimester, oth 10/1/2015 12/31/2299 O3622X0 Maternal care for hydrops fetalis, second trimester, unsp 10/1/2015 12/31/2299 O3622X1 Maternal care for hydrops fetalis, second trimester, fetus 1 10/1/2015 12/31/2299
156 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3622X2 Maternal care for hydrops fetalis, second trimester, fetus 2 10/1/2015 12/31/2299 O3622X3 Maternal care for hydrops fetalis, second trimester, fetus 3 10/1/2015 12/31/2299 O3622X4 Maternal care for hydrops fetalis, second trimester, fetus 4 10/1/2015 12/31/2299 O3622X5 Maternal care for hydrops fetalis, second trimester, fetus 5 10/1/2015 12/31/2299 O3622X9 Maternal care for hydrops fetalis, second trimester, oth 10/1/2015 12/31/2299 O3623X0 Maternal care for hydrops fetalis, third trimester, unsp 10/1/2015 12/31/2299 O3623X1 Maternal care for hydrops fetalis, third trimester, fetus 1 10/1/2015 12/31/2299 O3623X2 Maternal care for hydrops fetalis, third trimester, fetus 2 10/1/2015 12/31/2299 O3623X3 Maternal care for hydrops fetalis, third trimester, fetus 3 10/1/2015 12/31/2299 O3623X4 Maternal care for hydrops fetalis, third trimester, fetus 4 10/1/2015 12/31/2299 O3623X5 Maternal care for hydrops fetalis, third trimester, fetus 5 10/1/2015 12/31/2299 O3623X9 Maternal care for hydrops fetalis, third trimester, oth 10/1/2015 12/31/2299 O364XX0 Maternal care for intrauterine death, not applicable or unsp 10/1/2015 12/31/2299 O364XX1 Maternal care for intrauterine death, fetus 1 10/1/2015 12/31/2299 O364XX2 Maternal care for intrauterine death, fetus 2 10/1/2015 12/31/2299 O364XX3 Maternal care for intrauterine death, fetus 3 10/1/2015 12/31/2299 O364XX4 Maternal care for intrauterine death, fetus 4 10/1/2015 12/31/2299 O364XX5 Maternal care for intrauterine death, fetus 5 10/1/2015 12/31/2299 O364XX9 Maternal care for intrauterine death, other fetus 10/1/2015 12/31/2299 O365110 Matern care for known or susp placntl insuff, 1st tri, unsp 10/1/2015 12/31/2299 O365111 Matern care for known or susp placntl insuff, 1st tri, fts1 10/1/2015 12/31/2299 O365112 Matern care for known or susp placntl insuff, 1st tri, fts2 10/1/2015 12/31/2299 O365113 Matern care for known or susp placntl insuff, 1st tri, fts3 10/1/2015 12/31/2299 O365114 Matern care for known or susp placntl insuff, 1st tri, fts4 10/1/2015 12/31/2299 O365115 Matern care for known or susp placntl insuff, 1st tri, fts5 10/1/2015 12/31/2299 O365119 Matern care for known or susp placntl insuff, first tri, oth 10/1/2015 12/31/2299 O365120 Matern care for known or susp placntl insuff, 2nd tri, unsp 10/1/2015 12/31/2299 O365121 Matern care for known or susp placntl insuff, 2nd tri, fts1 10/1/2015 12/31/2299 O365122 Matern care for known or susp placntl insuff, 2nd tri, fts2 10/1/2015 12/31/2299 O365123 Matern care for known or susp placntl insuff, 2nd tri, fts3 10/1/2015 12/31/2299 O365124 Matern care for known or susp placntl insuff, 2nd tri, fts4 10/1/2015 12/31/2299 O365125 Matern care for known or susp placntl insuff, 2nd tri, fts5 10/1/2015 12/31/2299
157 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O365129 Matern care for known or susp placntl insuff, 2nd tri, oth 10/1/2015 12/31/2299 O365130 Matern care for or susp placntl insuff, third tri, unsp 10/1/2015 12/31/2299 O365131 Matern care for or susp placntl insuff, third tri, fts1 10/1/2015 12/31/2299 O365132 Matern care for or susp placntl insuff, third tri, fts2 10/1/2015 12/31/2299 O365133 Matern care for or susp placntl insuff, third tri, fts3 10/1/2015 12/31/2299 O365134 Matern care for or susp placntl insuff, third tri, fts4 10/1/2015 12/31/2299 O365135 Matern care for or susp placntl insuff, third tri, fts5 10/1/2015 12/31/2299 O365139 Matern care for known or susp placntl insuff, third tri, oth 10/1/2015 12/31/2299 O365910 Matern care for oth or susp poor fetl grth, 1st tri, unsp 10/1/2015 12/31/2299 O365911 Matern care for oth or susp poor fetl grth, 1st tri, fts1 10/1/2015 12/31/2299 O365912 Matern care for oth or susp poor fetl grth, 1st tri, fts2 10/1/2015 12/31/2299 O365913 Matern care for oth or susp poor fetl grth, 1st tri, fts3 10/1/2015 12/31/2299 O365914 Matern care for oth or susp poor fetl grth, 1st tri, fts4 10/1/2015 12/31/2299 O365915 Matern care for oth or susp poor fetl grth, 1st tri, fts5 10/1/2015 12/31/2299 O365919 Matern care for oth or susp poor fetl grth, 1st tri, oth 10/1/2015 12/31/2299 O365920 Matern care for oth or susp poor fetl grth, 2nd tri, unsp 10/1/2015 12/31/2299 O365921 Matern care for oth or susp poor fetl grth, 2nd tri, fts1 10/1/2015 12/31/2299 O365922 Matern care for oth or susp poor fetl grth, 2nd tri, fts2 10/1/2015 12/31/2299 O365923 Matern care for oth or susp poor fetl grth, 2nd tri, fts3 10/1/2015 12/31/2299 O365924 Matern care for oth or susp poor fetl grth, 2nd tri, fts4 10/1/2015 12/31/2299 O365925 Matern care for oth or susp poor fetl grth, 2nd tri, fts5 10/1/2015 12/31/2299 O365929 Matern care for oth or susp poor fetl grth, 2nd tri, oth 10/1/2015 12/31/2299 O365930 Matern care for oth or susp poor fetl grth, third tri, unsp 10/1/2015 12/31/2299 O365931 Matern care for oth or susp poor fetl grth, third tri, fts1 10/1/2015 12/31/2299 O365932 Matern care for oth or susp poor fetl grth, third tri, fts2 10/1/2015 12/31/2299 O365933 Matern care for oth or susp poor fetl grth, third tri, fts3 10/1/2015 12/31/2299 O365934 Matern care for oth or susp poor fetl grth, third tri, fts4 10/1/2015 12/31/2299 O365935 Matern care for oth or susp poor fetl grth, third tri, fts5 10/1/2015 12/31/2299 O365939 Matern care for oth or susp poor fetl grth, third tri, oth 10/1/2015 12/31/2299 O3661X0 Maternal care for excess fetal growth, first trimester, unsp 10/1/2015 12/31/2299 O3661X1 Maternal care for excess fetal growth, first tri, fetus 1 10/1/2015 12/31/2299 O3661X2 Maternal care for excess fetal growth, first tri, fetus 2 10/1/2015 12/31/2299
158 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3661X3 Maternal care for excess fetal growth, first tri, fetus 3 10/1/2015 12/31/2299 O3661X4 Maternal care for excess fetal growth, first tri, fetus 4 10/1/2015 12/31/2299 O3661X5 Maternal care for excess fetal growth, first tri, fetus 5 10/1/2015 12/31/2299 O3661X9 Maternal care for excess fetal growth, first trimester, oth 10/1/2015 12/31/2299 O3662X0 Maternal care for excess fetal growth, second tri, unsp 10/1/2015 12/31/2299 O3662X1 Maternal care for excess fetal growth, second tri, fetus 1 10/1/2015 12/31/2299 O3662X2 Maternal care for excess fetal growth, second tri, fetus 2 10/1/2015 12/31/2299 O3662X3 Maternal care for excess fetal growth, second tri, fetus 3 10/1/2015 12/31/2299 O3662X4 Maternal care for excess fetal growth, second tri, fetus 4 10/1/2015 12/31/2299 O3662X5 Maternal care for excess fetal growth, second tri, fetus 5 10/1/2015 12/31/2299 O3662X9 Maternal care for excess fetal growth, second trimester, oth 10/1/2015 12/31/2299 O3663X0 Maternal care for excess fetal growth, third trimester, unsp 10/1/2015 12/31/2299 O3663X1 Maternal care for excess fetal growth, third tri, fetus 1 10/1/2015 12/31/2299 O3663X2 Maternal care for excess fetal growth, third tri, fetus 2 10/1/2015 12/31/2299 O3663X3 Maternal care for excess fetal growth, third tri, fetus 3 10/1/2015 12/31/2299 O3663X4 Maternal care for excess fetal growth, third tri, fetus 4 10/1/2015 12/31/2299 O3663X5 Maternal care for excess fetal growth, third tri, fetus 5 10/1/2015 12/31/2299 O3663X9 Maternal care for excess fetal growth, third trimester, oth 10/1/2015 12/31/2299 O3671X0 Maternal care for viable fetus in abd preg, first tri, unsp 10/1/2015 12/31/2299 O3671X1 Matern care for viable fetus in abd preg, first tri, fetus 1 10/1/2015 12/31/2299 O3671X2 Matern care for viable fetus in abd preg, first tri, fetus 2 10/1/2015 12/31/2299 O3671X3 Matern care for viable fetus in abd preg, first tri, fetus 3 10/1/2015 12/31/2299 O3671X4 Matern care for viable fetus in abd preg, first tri, fetus 4 10/1/2015 12/31/2299 O3671X5 Matern care for viable fetus in abd preg, first tri, fetus 5 10/1/2015 12/31/2299 O3671X9 Maternal care for viable fetus in abd preg, first tri, oth 10/1/2015 12/31/2299 O3672X0 Maternal care for viable fetus in abd preg, second tri, unsp 10/1/2015 12/31/2299 O3672X1 Matern care for viable fetus in abd preg, second tri, fts1 10/1/2015 12/31/2299 O3672X2 Matern care for viable fetus in abd preg, second tri, fts2 10/1/2015 12/31/2299 O3672X3 Matern care for viable fetus in abd preg, second tri, fts3 10/1/2015 12/31/2299 O3672X4 Matern care for viable fetus in abd preg, second tri, fts4 10/1/2015 12/31/2299 O3672X5 Matern care for viable fetus in abd preg, second tri, fts5 10/1/2015 12/31/2299 O3672X9 Maternal care for viable fetus in abd preg, second tri, oth 10/1/2015 12/31/2299
159 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3673X0 Maternal care for viable fetus in abd preg, third tri, unsp 10/1/2015 12/31/2299 O3673X1 Matern care for viable fetus in abd preg, third tri, fetus 1 10/1/2015 12/31/2299 O3673X2 Matern care for viable fetus in abd preg, third tri, fetus 2 10/1/2015 12/31/2299 O3673X3 Matern care for viable fetus in abd preg, third tri, fetus 3 10/1/2015 12/31/2299 O3673X4 Matern care for viable fetus in abd preg, third tri, fetus 4 10/1/2015 12/31/2299 O3673X5 Matern care for viable fetus in abd preg, third tri, fetus 5 10/1/2015 12/31/2299 O3673X9 Maternal care for viable fetus in abd preg, third tri, oth 10/1/2015 12/31/2299 O3680X0 Pregnancy w inconclusive fetal viability, unsp 10/1/2015 12/31/2299 O3680X1 Pregnancy with inconclusive fetal viability, fetus 1 10/1/2015 12/31/2299 O3680X2 Pregnancy with inconclusive fetal viability, fetus 2 10/1/2015 12/31/2299 O3680X3 Pregnancy with inconclusive fetal viability, fetus 3 10/1/2015 12/31/2299 O3680X4 Pregnancy with inconclusive fetal viability, fetus 4 10/1/2015 12/31/2299 O3680X5 Pregnancy with inconclusive fetal viability, fetus 5 10/1/2015 12/31/2299 O3680X9 Pregnancy with inconclusive fetal viability, other fetus 10/1/2015 12/31/2299 O368120 Decreased fetal movements, second trimester, unsp 10/1/2015 12/31/2299 O368121 Decreased fetal movements, second trimester, fetus 1 10/1/2015 12/31/2299 O368122 Decreased fetal movements, second trimester, fetus 2 10/1/2015 12/31/2299 O368123 Decreased fetal movements, second trimester, fetus 3 10/1/2015 12/31/2299 O368124 Decreased fetal movements, second trimester, fetus 4 10/1/2015 12/31/2299 O368125 Decreased fetal movements, second trimester, fetus 5 10/1/2015 12/31/2299 O368129 Decreased fetal movements, second trimester, other fetus 10/1/2015 12/31/2299 O368130 Decreased fetal movements, third trimester, unsp 10/1/2015 12/31/2299 O368131 Decreased fetal movements, third trimester, fetus 1 10/1/2015 12/31/2299 O368132 Decreased fetal movements, third trimester, fetus 2 10/1/2015 12/31/2299 O368133 Decreased fetal movements, third trimester, fetus 3 10/1/2015 12/31/2299 O368134 Decreased fetal movements, third trimester, fetus 4 10/1/2015 12/31/2299 O368135 Decreased fetal movements, third trimester, fetus 5 10/1/2015 12/31/2299 O368139 Decreased fetal movements, third trimester, other fetus 10/1/2015 12/31/2299 O368190 Decreased fetal movements, unsp trimester, unsp 10/1/2015 12/31/2299 O368191 Decreased fetal movements, unspecified trimester, fetus 1 10/1/2015 12/31/2299 O368192 Decreased fetal movements, unspecified trimester, fetus 2 10/1/2015 12/31/2299 O368193 Decreased fetal movements, unspecified trimester, fetus 3 10/1/2015 12/31/2299
160 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O368194 Decreased fetal movements, unspecified trimester, fetus 4 10/1/2015 12/31/2299 O368195 Decreased fetal movements, unspecified trimester, fetus 5 10/1/2015 12/31/2299 O368199 Decreased fetal movements, unsp trimester, other fetus 10/1/2015 12/31/2299 O368910 Maternal care for oth fetal problems, first trimester, unsp 10/1/2015 12/31/2299 O368911 Maternal care for oth fetal problems, first tri, fetus 1 10/1/2015 12/31/2299 O368912 Maternal care for oth fetal problems, first tri, fetus 2 10/1/2015 12/31/2299 O368913 Maternal care for oth fetal problems, first tri, fetus 3 10/1/2015 12/31/2299 O368914 Maternal care for oth fetal problems, first tri, fetus 4 10/1/2015 12/31/2299 O368915 Maternal care for oth fetal problems, first tri, fetus 5 10/1/2015 12/31/2299 O368919 Maternal care for oth fetal problems, first trimester, oth 10/1/2015 12/31/2299 O368920 Maternal care for oth fetal problems, second trimester, unsp 10/1/2015 12/31/2299 O368921 Maternal care for oth fetal problems, second tri, fetus 1 10/1/2015 12/31/2299 O368922 Maternal care for oth fetal problems, second tri, fetus 2 10/1/2015 12/31/2299 O368923 Maternal care for oth fetal problems, second tri, fetus 3 10/1/2015 12/31/2299 O368924 Maternal care for oth fetal problems, second tri, fetus 4 10/1/2015 12/31/2299 O368925 Maternal care for oth fetal problems, second tri, fetus 5 10/1/2015 12/31/2299 O368929 Maternal care for oth fetal problems, second trimester, oth 10/1/2015 12/31/2299 O368930 Maternal care for oth fetal problems, third trimester, unsp 10/1/2015 12/31/2299 O368931 Maternal care for oth fetal problems, third tri, fetus 1 10/1/2015 12/31/2299 O368932 Maternal care for oth fetal problems, third tri, fetus 2 10/1/2015 12/31/2299 O368933 Maternal care for oth fetal problems, third tri, fetus 3 10/1/2015 12/31/2299 O368934 Maternal care for oth fetal problems, third tri, fetus 4 10/1/2015 12/31/2299 O368935 Maternal care for oth fetal problems, third tri, fetus 5 10/1/2015 12/31/2299 O368939 Maternal care for oth fetal problems, third trimester, oth 10/1/2015 12/31/2299 O3691X0 Maternal care for fetal problem, unsp, first trimester, unsp 10/1/2015 12/31/2299 O3691X1 Maternal care for fetal problem, unsp, first tri, fetus 1 10/1/2015 12/31/2299 O3691X2 Maternal care for fetal problem, unsp, first tri, fetus 2 10/1/2015 12/31/2299 O3691X3 Maternal care for fetal problem, unsp, first tri, fetus 3 10/1/2015 12/31/2299 O3691X4 Maternal care for fetal problem, unsp, first tri, fetus 4 10/1/2015 12/31/2299 O3691X5 Maternal care for fetal problem, unsp, first tri, fetus 5 10/1/2015 12/31/2299 O3691X9 Maternal care for fetal problem, unsp, first trimester, oth 10/1/2015 12/31/2299 O3692X0 Maternal care for fetal problem, unsp, second tri, unsp 10/1/2015 12/31/2299
161 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3692X1 Maternal care for fetal problem, unsp, second tri, fetus 1 10/1/2015 12/31/2299 O3692X2 Maternal care for fetal problem, unsp, second tri, fetus 2 10/1/2015 12/31/2299 O3692X3 Maternal care for fetal problem, unsp, second tri, fetus 3 10/1/2015 12/31/2299 O3692X4 Maternal care for fetal problem, unsp, second tri, fetus 4 10/1/2015 12/31/2299 O3692X5 Maternal care for fetal problem, unsp, second tri, fetus 5 10/1/2015 12/31/2299 O3692X9 Maternal care for fetal problem, unsp, second trimester, oth 10/1/2015 12/31/2299 O3693X0 Maternal care for fetal problem, unsp, third trimester, unsp 10/1/2015 12/31/2299 O3693X1 Maternal care for fetal problem, unsp, third tri, fetus 1 10/1/2015 12/31/2299 O3693X2 Maternal care for fetal problem, unsp, third tri, fetus 2 10/1/2015 12/31/2299 O3693X3 Maternal care for fetal problem, unsp, third tri, fetus 3 10/1/2015 12/31/2299 O3693X4 Maternal care for fetal problem, unsp, third tri, fetus 4 10/1/2015 12/31/2299 O3693X5 Maternal care for fetal problem, unsp, third tri, fetus 5 10/1/2015 12/31/2299 O3693X9 Maternal care for fetal problem, unsp, third trimester, oth 10/1/2015 12/31/2299 O401XX0 Polyhydramnios, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O401XX1 Polyhydramnios, first trimester, fetus 1 10/1/2015 12/31/2299 O401XX2 Polyhydramnios, first trimester, fetus 2 10/1/2015 12/31/2299 O401XX3 Polyhydramnios, first trimester, fetus 3 10/1/2015 12/31/2299 O401XX4 Polyhydramnios, first trimester, fetus 4 10/1/2015 12/31/2299 O401XX5 Polyhydramnios, first trimester, fetus 5 10/1/2015 12/31/2299 O401XX9 Polyhydramnios, first trimester, other fetus 10/1/2015 12/31/2299 O402XX0 Polyhydramnios, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O402XX1 Polyhydramnios, second trimester, fetus 1 10/1/2015 12/31/2299 O402XX2 Polyhydramnios, second trimester, fetus 2 10/1/2015 12/31/2299 O402XX3 Polyhydramnios, second trimester, fetus 3 10/1/2015 12/31/2299 O402XX4 Polyhydramnios, second trimester, fetus 4 10/1/2015 12/31/2299 O402XX5 Polyhydramnios, second trimester, fetus 5 10/1/2015 12/31/2299 O402XX9 Polyhydramnios, second trimester, other fetus 10/1/2015 12/31/2299 O403XX0 Polyhydramnios, third trimester, not applicable or unsp 10/1/2015 12/31/2299 O403XX1 Polyhydramnios, third trimester, fetus 1 10/1/2015 12/31/2299 O403XX2 Polyhydramnios, third trimester, fetus 2 10/1/2015 12/31/2299 O403XX3 Polyhydramnios, third trimester, fetus 3 10/1/2015 12/31/2299 O403XX4 Polyhydramnios, third trimester, fetus 4 10/1/2015 12/31/2299
162 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O403XX5 Polyhydramnios, third trimester, fetus 5 10/1/2015 12/31/2299 O403XX9 Polyhydramnios, third trimester, other fetus 10/1/2015 12/31/2299 O4101X0 Oligohydramnios, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O4101X1 Oligohydramnios, first trimester, fetus 1 10/1/2015 12/31/2299 O4101X2 Oligohydramnios, first trimester, fetus 2 10/1/2015 12/31/2299 O4101X3 Oligohydramnios, first trimester, fetus 3 10/1/2015 12/31/2299 O4101X4 Oligohydramnios, first trimester, fetus 4 10/1/2015 12/31/2299 O4101X5 Oligohydramnios, first trimester, fetus 5 10/1/2015 12/31/2299 O4101X9 Oligohydramnios, first trimester, other fetus 10/1/2015 12/31/2299 O4102X0 Oligohydramnios, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O4102X1 Oligohydramnios, second trimester, fetus 1 10/1/2015 12/31/2299 O4102X2 Oligohydramnios, second trimester, fetus 2 10/1/2015 12/31/2299 O4102X3 Oligohydramnios, second trimester, fetus 3 10/1/2015 12/31/2299 O4102X4 Oligohydramnios, second trimester, fetus 4 10/1/2015 12/31/2299 O4102X5 Oligohydramnios, second trimester, fetus 5 10/1/2015 12/31/2299 O4102X9 Oligohydramnios, second trimester, other fetus 10/1/2015 12/31/2299 O4103X0 Oligohydramnios, third trimester, not applicable or unsp 10/1/2015 12/31/2299 O4103X1 Oligohydramnios, third trimester, fetus 1 10/1/2015 12/31/2299 O4103X2 Oligohydramnios, third trimester, fetus 2 10/1/2015 12/31/2299 O4103X3 Oligohydramnios, third trimester, fetus 3 10/1/2015 12/31/2299 O4103X4 Oligohydramnios, third trimester, fetus 4 10/1/2015 12/31/2299 O4103X5 Oligohydramnios, third trimester, fetus 5 10/1/2015 12/31/2299 O4103X9 Oligohydramnios, third trimester, other fetus 10/1/2015 12/31/2299 O411010 Infct of amniotic sac and membrns, unsp, first tri, unsp 10/1/2015 12/31/2299 O411011 Infct of amniotic sac and membrns, unsp, first tri, fetus 1 10/1/2015 12/31/2299 O411012 Infct of amniotic sac and membrns, unsp, first tri, fetus 2 10/1/2015 12/31/2299 O411013 Infct of amniotic sac and membrns, unsp, first tri, fetus 3 10/1/2015 12/31/2299 O411014 Infct of amniotic sac and membrns, unsp, first tri, fetus 4 10/1/2015 12/31/2299 O411015 Infct of amniotic sac and membrns, unsp, first tri, fetus 5 10/1/2015 12/31/2299 O411019 Infct of amniotic sac and membrns, unsp, first tri, oth 10/1/2015 12/31/2299 O411020 Infct of amniotic sac and membrns, unsp, second tri, unsp 10/1/2015 12/31/2299 O411021 Infct of amniotic sac and membrns, unsp, second tri, fetus 1 10/1/2015 12/31/2299
163 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O411022 Infct of amniotic sac and membrns, unsp, second tri, fetus 2 10/1/2015 12/31/2299 O411023 Infct of amniotic sac and membrns, unsp, second tri, fetus 3 10/1/2015 12/31/2299 O411024 Infct of amniotic sac and membrns, unsp, second tri, fetus 4 10/1/2015 12/31/2299 O411025 Infct of amniotic sac and membrns, unsp, second tri, fetus 5 10/1/2015 12/31/2299 O411029 Infct of amniotic sac and membrns, unsp, second tri, oth 10/1/2015 12/31/2299 O411030 Infct of amniotic sac and membrns, unsp, third tri, unsp 10/1/2015 12/31/2299 O411031 Infct of amniotic sac and membrns, unsp, third tri, fetus 1 10/1/2015 12/31/2299 O411032 Infct of amniotic sac and membrns, unsp, third tri, fetus 2 10/1/2015 12/31/2299 O411033 Infct of amniotic sac and membrns, unsp, third tri, fetus 3 10/1/2015 12/31/2299 O411034 Infct of amniotic sac and membrns, unsp, third tri, fetus 4 10/1/2015 12/31/2299 O411035 Infct of amniotic sac and membrns, unsp, third tri, fetus 5 10/1/2015 12/31/2299 O411039 Infct of amniotic sac and membrns, unsp, third tri, oth 10/1/2015 12/31/2299 O411210 Chorioamnionitis, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O411211 Chorioamnionitis, first trimester, fetus 1 10/1/2015 12/31/2299 O411212 Chorioamnionitis, first trimester, fetus 2 10/1/2015 12/31/2299 O411213 Chorioamnionitis, first trimester, fetus 3 10/1/2015 12/31/2299 O411214 Chorioamnionitis, first trimester, fetus 4 10/1/2015 12/31/2299 O411215 Chorioamnionitis, first trimester, fetus 5 10/1/2015 12/31/2299 O411219 Chorioamnionitis, first trimester, other fetus 10/1/2015 12/31/2299 O411220 Chorioamnionitis, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O411221 Chorioamnionitis, second trimester, fetus 1 10/1/2015 12/31/2299 O411222 Chorioamnionitis, second trimester, fetus 2 10/1/2015 12/31/2299 O411223 Chorioamnionitis, second trimester, fetus 3 10/1/2015 12/31/2299 O411224 Chorioamnionitis, second trimester, fetus 4 10/1/2015 12/31/2299 O411225 Chorioamnionitis, second trimester, fetus 5 10/1/2015 12/31/2299 O411229 Chorioamnionitis, second trimester, other fetus 10/1/2015 12/31/2299 O411230 Chorioamnionitis, third trimester, not applicable or unsp 10/1/2015 12/31/2299 O411231 Chorioamnionitis, third trimester, fetus 1 10/1/2015 12/31/2299 O411232 Chorioamnionitis, third trimester, fetus 2 10/1/2015 12/31/2299 O411233 Chorioamnionitis, third trimester, fetus 3 10/1/2015 12/31/2299 O411234 Chorioamnionitis, third trimester, fetus 4 10/1/2015 12/31/2299 O411235 Chorioamnionitis, third trimester, fetus 5 10/1/2015 12/31/2299
164 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O411239 Chorioamnionitis, third trimester, other fetus 10/1/2015 12/31/2299 O411410 Placentitis, first trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411411 Placentitis, first trimester, fetus 1 10/1/2015 12/31/2299 O411412 Placentitis, first trimester, fetus 2 10/1/2015 12/31/2299 O411413 Placentitis, first trimester, fetus 3 10/1/2015 12/31/2299 O411414 Placentitis, first trimester, fetus 4 10/1/2015 12/31/2299 O411415 Placentitis, first trimester, fetus 5 10/1/2015 12/31/2299 O411419 Placentitis, first trimester, other fetus 10/1/2015 12/31/2299 O411420 Placentitis, second trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411421 Placentitis, second trimester, fetus 1 10/1/2015 12/31/2299 O411422 Placentitis, second trimester, fetus 2 10/1/2015 12/31/2299 O411423 Placentitis, second trimester, fetus 3 10/1/2015 12/31/2299 O411424 Placentitis, second trimester, fetus 4 10/1/2015 12/31/2299 O411425 Placentitis, second trimester, fetus 5 10/1/2015 12/31/2299 O411429 Placentitis, second trimester, other fetus 10/1/2015 12/31/2299 O411430 Placentitis, third trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411431 Placentitis, third trimester, fetus 1 10/1/2015 12/31/2299 O411432 Placentitis, third trimester, fetus 2 10/1/2015 12/31/2299 O411433 Placentitis, third trimester, fetus 3 10/1/2015 12/31/2299 O411434 Placentitis, third trimester, fetus 4 10/1/2015 12/31/2299 O411435 Placentitis, third trimester, fetus 5 10/1/2015 12/31/2299 O411439 Placentitis, third trimester, other fetus 10/1/2015 12/31/2299 O418X10 Oth disrd of amniotic fluid and membrns, first tri, unsp 10/1/2015 12/31/2299 O418X11 Oth disrd of amniotic fluid and membrns, first tri, fetus 1 10/1/2015 12/31/2299 O418X12 Oth disrd of amniotic fluid and membrns, first tri, fetus 2 10/1/2015 12/31/2299 O418X13 Oth disrd of amniotic fluid and membrns, first tri, fetus 3 10/1/2015 12/31/2299 O418X14 Oth disrd of amniotic fluid and membrns, first tri, fetus 4 10/1/2015 12/31/2299 O418X15 Oth disrd of amniotic fluid and membrns, first tri, fetus 5 10/1/2015 12/31/2299 O418X19 Oth disrd of amniotic fluid and membrns, first tri, oth 10/1/2015 12/31/2299 O418X20 Oth disrd of amniotic fluid and membrns, second tri, unsp 10/1/2015 12/31/2299 O418X21 Oth disrd of amniotic fluid and membrns, second tri, fetus 1 10/1/2015 12/31/2299 O418X22 Oth disrd of amniotic fluid and membrns, second tri, fetus 2 10/1/2015 12/31/2299
165 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O418X23 Oth disrd of amniotic fluid and membrns, second tri, fetus 3 10/1/2015 12/31/2299 O418X24 Oth disrd of amniotic fluid and membrns, second tri, fetus 4 10/1/2015 12/31/2299 O418X25 Oth disrd of amniotic fluid and membrns, second tri, fetus 5 10/1/2015 12/31/2299 O418X29 Oth disrd of amniotic fluid and membrns, second tri, oth 10/1/2015 12/31/2299 O418X30 Oth disrd of amniotic fluid and membrns, third tri, unsp 10/1/2015 12/31/2299 O418X31 Oth disrd of amniotic fluid and membrns, third tri, fetus 1 10/1/2015 12/31/2299 O418X32 Oth disrd of amniotic fluid and membrns, third tri, fetus 2 10/1/2015 12/31/2299 O418X33 Oth disrd of amniotic fluid and membrns, third tri, fetus 3 10/1/2015 12/31/2299 O418X34 Oth disrd of amniotic fluid and membrns, third tri, fetus 4 10/1/2015 12/31/2299 O418X35 Oth disrd of amniotic fluid and membrns, third tri, fetus 5 10/1/2015 12/31/2299 O418X39 Oth disrd of amniotic fluid and membrns, third tri, oth 10/1/2015 12/31/2299 O4191X0 Disorder of amnio fluid and membrns, unsp, first tri, unsp 10/1/2015 12/31/2299 O4191X1 Disord of amnio fluid and membrns, unsp, first tri, fetus 1 10/1/2015 12/31/2299 O4191X2 Disord of amnio fluid and membrns, unsp, first tri, fetus 2 10/1/2015 12/31/2299 O4191X3 Disord of amnio fluid and membrns, unsp, first tri, fetus 3 10/1/2015 12/31/2299 O4191X4 Disord of amnio fluid and membrns, unsp, first tri, fetus 4 10/1/2015 12/31/2299 O4191X5 Disord of amnio fluid and membrns, unsp, first tri, fetus 5 10/1/2015 12/31/2299 O4191X9 Disorder of amniotic fluid and membrns, unsp, first tri, oth 10/1/2015 12/31/2299 O4192X0 Disorder of amnio fluid and membrns, unsp, second tri, unsp 10/1/2015 12/31/2299 O4192X1 Disord of amnio fluid and membrns, unsp, second tri, fetus 1 10/1/2015 12/31/2299 O4192X2 Disord of amnio fluid and membrns, unsp, second tri, fetus 2 10/1/2015 12/31/2299 O4192X3 Disord of amnio fluid and membrns, unsp, second tri, fetus 3 10/1/2015 12/31/2299 O4192X4 Disord of amnio fluid and membrns, unsp, second tri, fetus 4 10/1/2015 12/31/2299 O4192X5 Disord of amnio fluid and membrns, unsp, second tri, fetus 5 10/1/2015 12/31/2299 O4192X9 Disorder of amnio fluid and membrns, unsp, second tri, oth 10/1/2015 12/31/2299 O4193X0 Disorder of amnio fluid and membrns, unsp, third tri, unsp 10/1/2015 12/31/2299 O4193X1 Disord of amnio fluid and membrns, unsp, third tri, fetus 1 10/1/2015 12/31/2299 O4193X2 Disord of amnio fluid and membrns, unsp, third tri, fetus 2 10/1/2015 12/31/2299 O4193X3 Disord of amnio fluid and membrns, unsp, third tri, fetus 3 10/1/2015 12/31/2299 O4193X4 Disord of amnio fluid and membrns, unsp, third tri, fetus 4 10/1/2015 12/31/2299 O4193X5 Disord of amnio fluid and membrns, unsp, third tri, fetus 5 10/1/2015 12/31/2299 O4193X9 Disorder of amniotic fluid and membrns, unsp, third tri, oth 10/1/2015 12/31/2299
166 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O42011 Pretrm prem ROM, onset labor w/n 24 hours of rupt, first tri 10/1/2015 12/31/2299 O42012 Pretrm prem ROM, onset labor w/n 24 hours of rupt, 2nd tri 10/1/2015 12/31/2299 O42013 Pretrm prem ROM, onset labor w/n 24 hours of rupt, third tri 10/1/2015 12/31/2299 O42111 Pretrm prem ROM, onset labor > 24 hours fol rupt, first tri 10/1/2015 12/31/2299 O42112 Pretrm prem ROM, onset labor > 24 hours fol rupt, second tri 10/1/2015 12/31/2299 O42113 Pretrm prem ROM, onset labor > 24 hours fol rupt, third tri 10/1/2015 12/31/2299 O42911 Pretrm prem ROM, unsp time betw rupt and onset labr, 1st tri 10/1/2015 12/31/2299 O42912 Pretrm prem ROM, unsp time betw rupt and onset labr, 2nd tri 10/1/2015 12/31/2299 O42913 Pretrm prem ROM, unsp time betw rupt and onst labr, 3rd tri 10/1/2015 12/31/2299 O43011 Fetomaternal placental transfusion syndrome, first trimester 10/1/2015 12/31/2299 O43012 Fetomaternal placental transfuse syndrome, second trimester 10/1/2015 12/31/2299 O43013 Fetomaternal placental transfusion syndrome, third trimester 10/1/2015 12/31/2299 O43021 Fetus-to-fetus placental transfuse syndrome, first trimester 10/1/2015 12/31/2299 O43022 Fetus-to-fetus placntl transfuse syndrome, second trimester 10/1/2015 12/31/2299 O43023 Fetus-to-fetus placental transfuse syndrome, third trimester 10/1/2015 12/31/2299 O43101 Malformation of placenta, unspecified, first trimester 10/1/2015 12/31/2299 O43102 Malformation of placenta, unspecified, second trimester 10/1/2015 12/31/2299 O43103 Malformation of placenta, unspecified, third trimester 10/1/2015 12/31/2299 O43111 Circumvallate placenta, first trimester 10/1/2015 12/31/2299 O43112 Circumvallate placenta, second trimester 10/1/2015 12/31/2299 O43113 Circumvallate placenta, third trimester 10/1/2015 12/31/2299 O43191 Other malformation of placenta, first trimester 10/1/2015 12/31/2299 O43192 Other malformation of placenta, second trimester 10/1/2015 12/31/2299 O43193 Other malformation of placenta, third trimester 10/1/2015 12/31/2299 O43811 Placental infarction, first trimester 10/1/2015 12/31/2299 O43812 Placental infarction, second trimester 10/1/2015 12/31/2299 O43813 Placental infarction, third trimester 10/1/2015 12/31/2299 O43891 Other placental disorders, first trimester 10/1/2015 12/31/2299 O43892 Other placental disorders, second trimester 10/1/2015 12/31/2299 O43893 Other placental disorders, third trimester 10/1/2015 12/31/2299 O4391 Unspecified placental disorder, first trimester 10/1/2015 12/31/2299 O4392 Unspecified placental disorder, second trimester 10/1/2015 12/31/2299
167 Table 11 ICD-10-CM Pregnancy Diagnosis Codes for Lab Procedures 81220-81224 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O4393 Unspecified placental disorder, third trimester 10/1/2015 12/31/2299 O610 Failed medical induction of labor 10/1/2015 12/31/2299 O611 Failed instrumental induction of labor 10/1/2015 12/31/2299 O68 Labor and delivery comp by abnlt of fetal acid-base balance 10/1/2015 12/31/2299 O752 Pyrexia during labor, not elsewhere classified 10/1/2015 12/31/2299 O753 Other infection during labor 10/1/2015 12/31/2299 O755 Delayed delivery after artificial rupture of membranes 10/1/2015 12/31/2299 O7589 Other specified complications of labor and delivery 10/1/2015 12/31/2299 O759 Complication of labor and delivery, unspecified 10/1/2015 12/31/2299 O76 Abnlt in fetal heart rate and rhythm comp labor and delivery 10/1/2015 12/31/2299 Z331 Pregnant state, incidental 10/1/2015 12/31/2299 Z31430 Encntr fem for test for genetc dis carrier stat for pro mgmt 1/1/2021 12/31/2299 Z31440 Encntr male test for genetic dis carrier status for pro mgmt 1/1/2021 12/31/2299 Z3400 Encntr for suprvsn of normal first pregnancy, unsp trimester 10/1/2015 12/31/2299 Z3401 Encntr for suprvsn of normal first preg, first trimester 10/1/2015 12/31/2299 Z3402 Encntr for suprvsn of normal first preg, second trimester 10/1/2015 12/31/2299 Z3403 Encntr for suprvsn of normal first preg, third trimester 10/1/2015 12/31/2299 Z3480 Encounter for suprvsn of normal pregnancy, unsp trimester 10/1/2015 12/31/2299 Z3481 Encounter for suprvsn of normal pregnancy, first trimester 10/1/2015 12/31/2299 Z3482 Encounter for suprvsn of normal pregnancy, second trimester 10/1/2015 12/31/2299 Z3483 Encounter for suprvsn of normal pregnancy, third trimester 10/1/2015 12/31/2299 Z3490 Encntr for suprvsn of normal pregnancy, unsp, unsp trimester 10/1/2015 12/31/2299 Z3491 Encntr for suprvsn of normal preg, unsp, first trimester 10/1/2015 12/31/2299 Z3492 Encntr for suprvsn of normal preg, unsp, second trimester 10/1/2015 12/31/2299 Z3493 Encntr for suprvsn of normal preg, unsp, third trimester 10/1/2015 12/31/2299
168 Table Listing, Previous Table 11, Next Table 12, End of Document
Table 11a: ICD-10-CM Diagnosis Codes for SMA Lab Procedure 81329
Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O0900 Suprvsn of preg w history of infertility, unsp trimester 1/1/2021 12/31/2299 O0901 Suprvsn of preg w history of infertility, first trimester 1/1/2021 12/31/2299 O0902 Suprvsn of preg w history of infertility, second trimester 1/1/2021 12/31/2299 O0903 Suprvsn of preg w history of infertility, third trimester 1/1/2021 12/31/2299 O0910 Suprvsn of preg with history of ectopic preg, unsp trimester 1/1/2021 12/31/2299 O0911 Suprvsn of preg with history of ectopic preg, first tri 1/1/2021 12/31/2299 O0912 Suprvsn of preg with history of ectopic preg, second tri 1/1/2021 12/31/2299 O0913 Suprvsn of preg with history of ectopic preg, third tri 1/1/2021 12/31/2299 O09211 Suprvsn of preg w history of pre-term labor, first trimester 1/1/2021 12/31/2299 O09212 Suprvsn of preg w history of pre-term labor, second tri 1/1/2021 12/31/2299 O09213 Suprvsn of preg w history of pre-term labor, third trimester 1/1/2021 12/31/2299 O09219 Suprvsn of preg w history of pre-term labor, unsp trimester 1/1/2021 12/31/2299 O09291 Suprvsn of preg w poor reprodctv or obstet hx, first tri 1/1/2021 12/31/2299 O09292 Suprvsn of preg w poor reprodctv or obstet hx, second tri 1/1/2021 12/31/2299 O09293 Suprvsn of preg w poor reprodctv or obstet hx, third tri 1/1/2021 12/31/2299 O09299 Suprvsn of preg w poor reprodctv or obstet history, unsp tri 1/1/2021 12/31/2299 O0930 Suprvsn of preg w insufficient antenat care, unsp trimester 1/1/2021 12/31/2299 O0931 Suprvsn of preg w insufficient antenat care, first trimester 1/1/2021 12/31/2299 O0932 Suprvsn of preg w insufficient antenat care, second tri 1/1/2021 12/31/2299 O0933 Suprvsn of preg w insufficient antenat care, third trimester 1/1/2021 12/31/2299 O0940 Supervision of pregnancy w grand multiparity, unsp trimester 1/1/2021 12/31/2299 O0941 Suprvsn of pregnancy w grand multiparity, first trimester 1/1/2021 12/31/2299 O0942 Suprvsn of pregnancy w grand multiparity, second trimester 1/1/2021 12/31/2299 O0943 Suprvsn of pregnancy w grand multiparity, third trimester 1/1/2021 12/31/2299 O09511 Supervision of elderly primigravida, first trimester 1/1/2021 12/31/2299 O09512 Supervision of elderly primigravida, second trimester 1/1/2021 12/31/2299 O09513 Supervision of elderly primigravida, third trimester 1/1/2021 12/31/2299 O09519 Supervision of elderly primigravida, unspecified trimester 1/1/2021 12/31/2299
169 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O09521 Supervision of elderly multigravida, first trimester 1/1/2021 12/31/2299 O09522 Supervision of elderly multigravida, second trimester 1/1/2021 12/31/2299 O09523 Supervision of elderly multigravida, third trimester 1/1/2021 12/31/2299 O09529 Supervision of elderly multigravida, unspecified trimester 1/1/2021 12/31/2299 O09611 Supervision of young primigravida, first trimester 1/1/2021 12/31/2299 O09612 Supervision of young primigravida, second trimester 1/1/2021 12/31/2299 O09613 Supervision of young primigravida, third trimester 1/1/2021 12/31/2299 O09619 Supervision of young primigravida, unspecified trimester 1/1/2021 12/31/2299 O09621 Supervision of young multigravida, first trimester 1/1/2021 12/31/2299 O09622 Supervision of young multigravida, second trimester 1/1/2021 12/31/2299 O09623 Supervision of young multigravida, third trimester 1/1/2021 12/31/2299 O09629 Supervision of young multigravida, unspecified trimester 1/1/2021 12/31/2299 O0970 Suprvsn of high risk preg due to social problems, unsp tri 1/1/2021 12/31/2299 O0971 Suprvsn of high risk preg due to social problems, first tri 1/1/2021 12/31/2299 O0972 Suprvsn of high risk preg due to social problems, second tri 1/1/2021 12/31/2299 O0973 Suprvsn of high risk preg due to social problems, third tri 1/1/2021 12/31/2299 O09811 Suprvsn of preg rslt from assisted reprodctv tech, first tri 1/1/2021 12/31/2299 O09812 Suprvsn of preg rslt from assist reprodctv tech, second tri 1/1/2021 12/31/2299 O09813 Suprvsn of preg rslt from assisted reprodctv tech, third tri 1/1/2021 12/31/2299 O09819 Suprvsn of preg rslt from assisted reprodctv tech, unsp tri 1/1/2021 12/31/2299 O09821 Suprvsn of preg w hx of in utero proc dur prev preg, 1st tri 1/1/2021 12/31/2299 O09822 Suprvsn of preg w hx of in utero proc dur prev preg, 2nd tri 1/1/2021 12/31/2299 O09823 Suprvsn of preg w hx of in utero proc dur prev preg, 3rd tri 1/1/2021 12/31/2299 O09829 Suprvsn of preg w hx of in utero proc dur prev preg,unsp tri 1/1/2021 12/31/2299 O09891 Supervision of other high risk pregnancies, first trimester 1/1/2021 12/31/2299 O09892 Supervision of other high risk pregnancies, second trimester 1/1/2021 12/31/2299 O09893 Supervision of other high risk pregnancies, third trimester 1/1/2021 12/31/2299 O09899 Supervision of other high risk pregnancies, unsp trimester 1/1/2021 12/31/2299 O0990 Supervision of high risk pregnancy, unsp, unsp trimester 1/1/2021 12/31/2299 O0991 Supervision of high risk pregnancy, unsp, first trimester 1/1/2021 12/31/2299 O0992 Supervision of high risk pregnancy, unsp, second trimester 1/1/2021 12/31/2299 O0993 Supervision of high risk pregnancy, unsp, third trimester 1/1/2021 12/31/2299
170 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O30001 Twin preg, unsp num plcnta & amnio sacs, first trimester 1/1/2021 12/31/2299 O30002 Twin preg, unsp num plcnta & amnio sacs, second trimester 1/1/2021 12/31/2299 O30003 Twin preg, unsp num plcnta & amnio sacs, third trimester 1/1/2021 12/31/2299 O30011 Twin pregnancy, monochorionic/monoamniotic, first trimester 1/1/2021 12/31/2299 O30012 Twin pregnancy, monochorionic/monoamniotic, second trimester 1/1/2021 12/31/2299 O30013 Twin pregnancy, monochorionic/monoamniotic, third trimester 1/1/2021 12/31/2299 O30031 Twin pregnancy, monochorionic/diamniotic, first trimester 1/1/2021 12/31/2299 O30032 Twin pregnancy, monochorionic/diamniotic, second trimester 1/1/2021 12/31/2299 O30033 Twin pregnancy, monochorionic/diamniotic, third trimester 1/1/2021 12/31/2299 O30041 Twin pregnancy, dichorionic/diamniotic, first trimester 1/1/2021 12/31/2299 O30042 Twin pregnancy, dichorionic/diamniotic, second trimester 1/1/2021 12/31/2299 O30043 Twin pregnancy, dichorionic/diamniotic, third trimester 1/1/2021 12/31/2299 O30091 Twin preg, unable to dtrm num plcnta & amnio sacs, first tri 1/1/2021 12/31/2299 O30092 Twin preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 1/1/2021 12/31/2299 O30093 Twin preg, unable to dtrm num plcnta & amnio sacs, third tri 1/1/2021 12/31/2299 O30101 Triplet preg, unsp num plcnta & amnio sacs, first trimester 1/1/2021 12/31/2299 O30102 Triplet preg, unsp num plcnta & amnio sacs, second trimester 1/1/2021 12/31/2299 O30103 Triplet preg, unsp num plcnta & amnio sacs, third trimester 1/1/2021 12/31/2299 O30111 Triplet preg w two or more monochorionic fetuses, first tri 1/1/2021 12/31/2299 O30112 Triplet preg w two or more monochorionic fetuses, second tri 1/1/2021 12/31/2299 O30113 Triplet preg w two or more monochorionic fetuses, third tri 1/1/2021 12/31/2299 O30121 Triplet preg w two or more monoamnio fetuses, first tri 1/1/2021 12/31/2299 O30122 Triplet preg w two or more monoamnio fetuses, second tri 1/1/2021 12/31/2299 O30123 Triplet preg w two or more monoamnio fetuses, third tri 1/1/2021 12/31/2299 O30191 Trp preg, unable to dtrm num plcnta & amnio sacs, first tri 1/1/2021 12/31/2299 O30192 Trp preg, unable to dtrm num plcnta & amnio sacs, second tri 1/1/2021 12/31/2299 O30193 Trp preg, unable to dtrm num plcnta & amnio sacs, third tri 1/1/2021 12/31/2299 O30201 Quad preg, unsp num plcnta & amnio sacs, first trimester 1/1/2021 12/31/2299 O30202 Quad preg, unsp num plcnta & amnio sacs, second trimester 1/1/2021 12/31/2299 O30203 Quad preg, unsp num plcnta & amnio sacs, third trimester 1/1/2021 12/31/2299 O30211 Quad preg w two or more monochorionic fetuses, first tri 1/1/2021 12/31/2299 O30212 Quad preg w two or more monochorionic fetuses, second tri 1/1/2021 12/31/2299
171 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O30213 Quad preg w two or more monochorionic fetuses, third tri 1/1/2021 12/31/2299 O30221 Quad preg w two or more monoamnio fetuses, first trimester 1/1/2021 12/31/2299 O30222 Quad preg w two or more monoamnio fetuses, second trimester 1/1/2021 12/31/2299 O30223 Quad preg w two or more monoamnio fetuses, third trimester 1/1/2021 12/31/2299 O30291 Quad preg, unable to dtrm num plcnta & amnio sacs, first tri 1/1/2021 12/31/2299 O30292 Quad preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 1/1/2021 12/31/2299 O30293 Quad preg, unable to dtrm num plcnta & amnio sacs, third tri 1/1/2021 12/31/2299 O30801 Oth multiple gest, unsp num plcnta & amnio sacs, first tri 1/1/2021 12/31/2299 O30802 Oth multiple gest, unsp num plcnta & amnio sacs, second tri 1/1/2021 12/31/2299 O30803 Oth multiple gest, unsp num plcnta & amnio sacs, third tri 1/1/2021 12/31/2299 O30811 Oth mult gest w two or more monochorionic fetuses, first tri 1/1/2021 12/31/2299 O30812 Oth mult gest w two or more monochorionic fetuses, 2nd tri 1/1/2021 12/31/2299 O30813 Oth mult gest w two or more monochorionic fetuses, third tri 1/1/2021 12/31/2299 O30821 Oth multiple gest w two or more monoamnio fetuses, first tri 1/1/2021 12/31/2299 O30822 Oth mult gest w two or more monoamnio fetuses, second tri 1/1/2021 12/31/2299 O30823 Oth multiple gest w two or more monoamnio fetuses, third tri 1/1/2021 12/31/2299 O30891 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 1st tri 1/1/2021 12/31/2299 O30892 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 2nd tri 1/1/2021 12/31/2299 O30893 Oth mult gest, unab to dtrm num plcnta & amnio sacs, 3rd tri 1/1/2021 12/31/2299 O3091 Multiple gestation, unspecified, first trimester 1/1/2021 12/31/2299 O3092 Multiple gestation, unspecified, second trimester 1/1/2021 12/31/2299 O3093 Multiple gestation, unspecified, third trimester 1/1/2021 12/31/2299 O3111X0 Cont preg aft spon abort of one fts or more, first tri, unsp 1/1/2021 12/31/2299 O3111X1 Cont preg aft spon abort of one fts or more, first tri, fts1 1/1/2021 12/31/2299 O3111X2 Cont preg aft spon abort of one fts or more, first tri, fts2 1/1/2021 12/31/2299 O3111X3 Cont preg aft spon abort of one fts or more, first tri, fts3 1/1/2021 12/31/2299 O3111X4 Cont preg aft spon abort of one fts or more, first tri, fts4 1/1/2021 12/31/2299 O3111X5 Cont preg aft spon abort of one fts or more, first tri, fts5 1/1/2021 12/31/2299 O3111X9 Cont preg aft spon abort of one fts or more, first tri, oth 1/1/2021 12/31/2299 O3112X0 Cont preg aft spon abort of one fetus or more, 2nd tri, unsp 1/1/2021 12/31/2299 O3112X1 Cont preg aft spon abort of one fetus or more, 2nd tri, fts1 1/1/2021 12/31/2299 O3112X2 Cont preg aft spon abort of one fetus or more, 2nd tri, fts2 1/1/2021 12/31/2299
172 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3112X3 Cont preg aft spon abort of one fetus or more, 2nd tri, fts3 1/1/2021 12/31/2299 O3112X4 Cont preg aft spon abort of one fetus or more, 2nd tri, fts4 1/1/2021 12/31/2299 O3112X5 Cont preg aft spon abort of one fetus or more, 2nd tri, fts5 1/1/2021 12/31/2299 O3112X9 Cont preg aft spon abort of one fetus or more, 2nd tri, oth 1/1/2021 12/31/2299 O3113X0 Cont preg aft spon abort of one fts or more, third tri, unsp 1/1/2021 12/31/2299 O3113X1 Cont preg aft spon abort of one fts or more, third tri, fts1 1/1/2021 12/31/2299 O3113X2 Cont preg aft spon abort of one fts or more, third tri, fts2 1/1/2021 12/31/2299 O3113X3 Cont preg aft spon abort of one fts or more, third tri, fts3 1/1/2021 12/31/2299 O3113X4 Cont preg aft spon abort of one fts or more, third tri, fts4 1/1/2021 12/31/2299 O3113X5 Cont preg aft spon abort of one fts or more, third tri, fts5 1/1/2021 12/31/2299 O3113X9 Cont preg aft spon abort of one fts or more, third tri, oth 1/1/2021 12/31/2299 O3121X0 Cont preg aft uterin dth of one fts or more, first tri, unsp 1/1/2021 12/31/2299 O3121X1 Cont preg aft uterin dth of one fts or more, first tri, fts1 1/1/2021 12/31/2299 O3121X2 Cont preg aft uterin dth of one fts or more, first tri, fts2 1/1/2021 12/31/2299 O3121X3 Cont preg aft uterin dth of one fts or more, first tri, fts3 1/1/2021 12/31/2299 O3121X4 Cont preg aft uterin dth of one fts or more, first tri, fts4 1/1/2021 12/31/2299 O3121X5 Cont preg aft uterin dth of one fts or more, first tri, fts5 1/1/2021 12/31/2299 O3121X9 Cont preg aft uterin dth of one fts or more, first tri, oth 1/1/2021 12/31/2299 O3122X0 Cont preg aft uterin dth of one fetus or more, 2nd tri, unsp 1/1/2021 12/31/2299 O3122X1 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts1 1/1/2021 12/31/2299 O3122X2 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts2 1/1/2021 12/31/2299 O3122X3 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts3 1/1/2021 12/31/2299 O3122X4 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts4 1/1/2021 12/31/2299 O3122X5 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts5 1/1/2021 12/31/2299 O3122X9 Cont preg aft uterin dth of one fetus or more, 2nd tri, oth 1/1/2021 12/31/2299 O3123X0 Cont preg aft uterin dth of one fts or more, third tri, unsp 1/1/2021 12/31/2299 O3123X1 Cont preg aft uterin dth of one fts or more, third tri, fts1 1/1/2021 12/31/2299 O3123X2 Cont preg aft uterin dth of one fts or more, third tri, fts2 1/1/2021 12/31/2299 O3123X3 Cont preg aft uterin dth of one fts or more, third tri, fts3 1/1/2021 12/31/2299 O3123X4 Cont preg aft uterin dth of one fts or more, third tri, fts4 1/1/2021 12/31/2299 O3123X5 Cont preg aft uterin dth of one fts or more, third tri, fts5 1/1/2021 12/31/2299 O3123X9 Cont preg aft uterin dth of one fts or more, third tri, oth 1/1/2021 12/31/2299
173 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3131X0 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, unsp 1/1/2021 12/31/2299 O3131X1 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts1 1/1/2021 12/31/2299 O3131X2 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts2 1/1/2021 12/31/2299 O3131X3 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts3 1/1/2021 12/31/2299 O3131X4 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts4 1/1/2021 12/31/2299 O3131X5 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts5 1/1/2021 12/31/2299 O3131X9 Cont preg aft elctv fetl rdct of 1 fts or more, 1st tri, oth 1/1/2021 12/31/2299 O3132X0 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, unsp 1/1/2021 12/31/2299 O3132X1 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts1 1/1/2021 12/31/2299 O3132X2 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts2 1/1/2021 12/31/2299 O3132X3 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts3 1/1/2021 12/31/2299 O3132X4 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts4 1/1/2021 12/31/2299 O3132X5 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts5 1/1/2021 12/31/2299 O3132X9 Cont preg aft elctv fetl rdct of 1 fts or more, 2nd tri, oth 1/1/2021 12/31/2299 O3133X0 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, unsp 1/1/2021 12/31/2299 O3133X1 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts1 1/1/2021 12/31/2299 O3133X2 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts2 1/1/2021 12/31/2299 O3133X3 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts3 1/1/2021 12/31/2299 O3133X4 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts4 1/1/2021 12/31/2299 O3133X5 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts5 1/1/2021 12/31/2299 O3133X9 Cont preg aft elctv fetl rdct of 1 fts or more, 3rd tri, oth 1/1/2021 12/31/2299 O318X10 Oth comp specific to multiple gest, first trimester, unsp 1/1/2021 12/31/2299 O318X11 Oth comp specific to multiple gest, first trimester, fetus 1 1/1/2021 12/31/2299 O318X12 Oth comp specific to multiple gest, first trimester, fetus 2 1/1/2021 12/31/2299 O318X13 Oth comp specific to multiple gest, first trimester, fetus 3 1/1/2021 12/31/2299 O318X14 Oth comp specific to multiple gest, first trimester, fetus 4 1/1/2021 12/31/2299 O318X15 Oth comp specific to multiple gest, first trimester, fetus 5 1/1/2021 12/31/2299 O318X19 Oth comp specific to multiple gest, first trimester, oth 1/1/2021 12/31/2299 O318X20 Oth comp specific to multiple gest, second trimester, unsp 1/1/2021 12/31/2299 O318X21 Oth comp specific to multiple gest, second tri, fetus 1 1/1/2021 12/31/2299 O318X22 Oth comp specific to multiple gest, second tri, fetus 2 1/1/2021 12/31/2299 O318X23 Oth comp specific to multiple gest, second tri, fetus 3 1/1/2021 12/31/2299
174 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O318X24 Oth comp specific to multiple gest, second tri, fetus 4 1/1/2021 12/31/2299 O318X25 Oth comp specific to multiple gest, second tri, fetus 5 1/1/2021 12/31/2299 O318X29 Oth comp specific to multiple gest, second trimester, oth 1/1/2021 12/31/2299 O318X30 Oth comp specific to multiple gest, third trimester, unsp 1/1/2021 12/31/2299 O318X31 Oth comp specific to multiple gest, third trimester, fetus 1 1/1/2021 12/31/2299 O318X32 Oth comp specific to multiple gest, third trimester, fetus 2 1/1/2021 12/31/2299 O318X33 Oth comp specific to multiple gest, third trimester, fetus 3 1/1/2021 12/31/2299 O318X34 Oth comp specific to multiple gest, third trimester, fetus 4 1/1/2021 12/31/2299 O318X35 Oth comp specific to multiple gest, third trimester, fetus 5 1/1/2021 12/31/2299 O318X39 Oth comp specific to multiple gest, third trimester, oth 1/1/2021 12/31/2299 O320XX0 Maternal care for unstable lie, not applicable or unsp 1/1/2021 12/31/2299 O320XX1 Maternal care for unstable lie, fetus 1 1/1/2021 12/31/2299 O320XX2 Maternal care for unstable lie, fetus 2 1/1/2021 12/31/2299 O320XX3 Maternal care for unstable lie, fetus 3 1/1/2021 12/31/2299 O320XX4 Maternal care for unstable lie, fetus 4 1/1/2021 12/31/2299 O320XX5 Maternal care for unstable lie, fetus 5 1/1/2021 12/31/2299 O320XX9 Maternal care for unstable lie, other fetus 1/1/2021 12/31/2299 O321XX0 Maternal care for breech presentation, unsp 1/1/2021 12/31/2299 O321XX1 Maternal care for breech presentation, fetus 1 1/1/2021 12/31/2299 O321XX2 Maternal care for breech presentation, fetus 2 1/1/2021 12/31/2299 O321XX3 Maternal care for breech presentation, fetus 3 1/1/2021 12/31/2299 O321XX4 Maternal care for breech presentation, fetus 4 1/1/2021 12/31/2299 O321XX5 Maternal care for breech presentation, fetus 5 1/1/2021 12/31/2299 O321XX9 Maternal care for breech presentation, other fetus 1/1/2021 12/31/2299 O322XX0 Maternal care for transverse and oblique lie, unsp 1/1/2021 12/31/2299 O322XX1 Maternal care for transverse and oblique lie, fetus 1 1/1/2021 12/31/2299 O322XX2 Maternal care for transverse and oblique lie, fetus 2 1/1/2021 12/31/2299 O322XX3 Maternal care for transverse and oblique lie, fetus 3 1/1/2021 12/31/2299 O322XX4 Maternal care for transverse and oblique lie, fetus 4 1/1/2021 12/31/2299 O322XX5 Maternal care for transverse and oblique lie, fetus 5 1/1/2021 12/31/2299 O322XX9 Maternal care for transverse and oblique lie, other fetus 1/1/2021 12/31/2299 O323XX0 Maternal care for face, brow and chin presentation, unsp 1/1/2021 12/31/2299
175 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O323XX1 Maternal care for face, brow and chin presentation, fetus 1 1/1/2021 12/31/2299 O323XX2 Maternal care for face, brow and chin presentation, fetus 2 1/1/2021 12/31/2299 O323XX3 Maternal care for face, brow and chin presentation, fetus 3 1/1/2021 12/31/2299 O323XX4 Maternal care for face, brow and chin presentation, fetus 4 1/1/2021 12/31/2299 O323XX5 Maternal care for face, brow and chin presentation, fetus 5 1/1/2021 12/31/2299 O323XX9 Maternal care for face, brow and chin presentation, oth 1/1/2021 12/31/2299 O324XX0 Maternal care for high head at term, not applicable or unsp 1/1/2021 12/31/2299 O324XX1 Maternal care for high head at term, fetus 1 1/1/2021 12/31/2299 O324XX2 Maternal care for high head at term, fetus 2 1/1/2021 12/31/2299 O324XX3 Maternal care for high head at term, fetus 3 1/1/2021 12/31/2299 O324XX4 Maternal care for high head at term, fetus 4 1/1/2021 12/31/2299 O324XX5 Maternal care for high head at term, fetus 5 1/1/2021 12/31/2299 O324XX9 Maternal care for high head at term, other fetus 1/1/2021 12/31/2299 O326XX0 Maternal care for compound presentation, unsp 1/1/2021 12/31/2299 O326XX1 Maternal care for compound presentation, fetus 1 1/1/2021 12/31/2299 O326XX2 Maternal care for compound presentation, fetus 2 1/1/2021 12/31/2299 O326XX3 Maternal care for compound presentation, fetus 3 1/1/2021 12/31/2299 O326XX4 Maternal care for compound presentation, fetus 4 1/1/2021 12/31/2299 O326XX5 Maternal care for compound presentation, fetus 5 1/1/2021 12/31/2299 O326XX9 Maternal care for compound presentation, other fetus 1/1/2021 12/31/2299 O328XX0 Maternal care for oth malpresentation of fetus, unsp 1/1/2021 12/31/2299 O328XX1 Maternal care for other malpresentation of fetus, fetus 1 1/1/2021 12/31/2299 O328XX2 Maternal care for other malpresentation of fetus, fetus 2 1/1/2021 12/31/2299 O328XX3 Maternal care for other malpresentation of fetus, fetus 3 1/1/2021 12/31/2299 O328XX4 Maternal care for other malpresentation of fetus, fetus 4 1/1/2021 12/31/2299 O328XX5 Maternal care for other malpresentation of fetus, fetus 5 1/1/2021 12/31/2299 O328XX9 Maternal care for oth malpresentation of fetus, other fetus 1/1/2021 12/31/2299 O329XX0 Maternal care for malpresentation of fetus, unsp, unsp 1/1/2021 12/31/2299 O329XX1 Maternal care for malpresentation of fetus, unsp, fetus 1 1/1/2021 12/31/2299 O329XX2 Maternal care for malpresentation of fetus, unsp, fetus 2 1/1/2021 12/31/2299 O329XX3 Maternal care for malpresentation of fetus, unsp, fetus 3 1/1/2021 12/31/2299 O329XX4 Maternal care for malpresentation of fetus, unsp, fetus 4 1/1/2021 12/31/2299
176 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O329XX5 Maternal care for malpresentation of fetus, unsp, fetus 5 1/1/2021 12/31/2299 O329XX9 Maternal care for malpresentation of fetus, unsp, oth fetus 1/1/2021 12/31/2299 O330 Matern care for disproprtn d/t deformity of matern pelv bone 1/1/2021 12/31/2299 O331 Matern care for disproprtn d/t generally contracted pelvis 1/1/2021 12/31/2299 O332 Maternal care for disproprtn due to inlet contrctn of pelvis 1/1/2021 12/31/2299 O333XX0 Matern care for disproprtn d/t outlet contrctn of pelv, unsp 1/1/2021 12/31/2299 O333XX1 Matern care for disproprtn d/t outlet contrctn of pelv, fts1 1/1/2021 12/31/2299 O333XX2 Matern care for disproprtn d/t outlet contrctn of pelv, fts2 1/1/2021 12/31/2299 O333XX3 Matern care for disproprtn d/t outlet contrctn of pelv, fts3 1/1/2021 12/31/2299 O333XX4 Matern care for disproprtn d/t outlet contrctn of pelv, fts4 1/1/2021 12/31/2299 O333XX5 Matern care for disproprtn d/t outlet contrctn of pelv, fts5 1/1/2021 12/31/2299 O333XX9 Matern care for disproprtn d/t outlet contrctn of pelv, oth 1/1/2021 12/31/2299 O334XX0 Matern care for disproprtn of mix matern & fetl origin, unsp 1/1/2021 12/31/2299 O334XX1 Matern care for disproprtn of mix matern & fetl origin, fts1 1/1/2021 12/31/2299 O334XX2 Matern care for disproprtn of mix matern & fetl origin, fts2 1/1/2021 12/31/2299 O334XX3 Matern care for disproprtn of mix matern & fetl origin, fts3 1/1/2021 12/31/2299 O334XX4 Matern care for disproprtn of mix matern & fetl origin, fts4 1/1/2021 12/31/2299 O334XX5 Matern care for disproprtn of mix matern & fetl origin, fts5 1/1/2021 12/31/2299 O334XX9 Matern care for disproprtn of mix matern & fetl origin, oth 1/1/2021 12/31/2299 O335XX0 Matern care for disproprtn d/t unusually large fetus, unsp 1/1/2021 12/31/2299 O335XX1 Matern care for disproprtn d/t unusually large fetus, fts1 1/1/2021 12/31/2299 O335XX2 Matern care for disproprtn d/t unusually large fetus, fts2 1/1/2021 12/31/2299 O335XX3 Matern care for disproprtn d/t unusually large fetus, fts3 1/1/2021 12/31/2299 O335XX4 Matern care for disproprtn d/t unusually large fetus, fts4 1/1/2021 12/31/2299 O335XX5 Matern care for disproprtn d/t unusually large fetus, fts5 1/1/2021 12/31/2299 O335XX9 Matern care for disproprtn due to unusually large fetus, oth 1/1/2021 12/31/2299 O336XX0 Matern care for disproprtn due to hydrocephalic fetus, unsp 1/1/2021 12/31/2299 O336XX1 Matern care for disproprtn due to hydrocephalic fetus, fts1 1/1/2021 12/31/2299 O336XX2 Matern care for disproprtn due to hydrocephalic fetus, fts2 1/1/2021 12/31/2299 O336XX3 Matern care for disproprtn due to hydrocephalic fetus, fts3 1/1/2021 12/31/2299 O336XX4 Matern care for disproprtn due to hydrocephalic fetus, fts4 1/1/2021 12/31/2299 O336XX5 Matern care for disproprtn due to hydrocephalic fetus, fts5 1/1/2021 12/31/2299
177 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O336XX9 Maternal care for disproprtn due to hydrocephalic fetus, oth 1/1/2021 12/31/2299 O337XX0 Maternal care for disproprtn due to other fetal deform, unsp 1/1/2021 12/31/2299 O337XX1 Matern care for disproprtn due to other fetal deform, fts1 1/1/2021 12/31/2299 O337XX2 Matern care for disproprtn due to other fetal deform, fts2 1/1/2021 12/31/2299 O337XX3 Matern care for disproprtn due to other fetal deform, fts3 1/1/2021 12/31/2299 O337XX4 Matern care for disproprtn due to other fetal deform, fts4 1/1/2021 12/31/2299 O337XX5 Matern care for disproprtn due to other fetal deform, fts5 1/1/2021 12/31/2299 O337XX9 Maternal care for disproprtn due to other fetal deform, oth 1/1/2021 12/31/2299 O338 Maternal care for disproportion of other origin 1/1/2021 12/31/2299 O339 Maternal care for disproportion, unspecified 1/1/2021 12/31/2299 O3401 Maternal care for unsp congen malform of uterus, first tri 1/1/2021 12/31/2299 O3402 Maternal care for unsp congen malform of uterus, second tri 1/1/2021 12/31/2299 O3403 Maternal care for unsp congen malform of uterus, third tri 1/1/2021 12/31/2299 O3411 Maternal care for benign tumor of corpus uteri, first tri 1/1/2021 12/31/2299 O3412 Maternal care for benign tumor of corpus uteri, second tri 1/1/2021 12/31/2299 O3413 Maternal care for benign tumor of corpus uteri, third tri 1/1/2021 12/31/2299 O34211 Matern care for low transverse scar from prev cesarean del 1/1/2021 12/31/2299 O34212 Maternal care for vertical scar from previous cesarean del 1/1/2021 12/31/2299 O34219 Maternal care for unsp type scar from previous cesarean del 1/1/2021 12/31/2299 O3429 Maternal care due to uterine scar from oth previous surgery 1/1/2021 12/31/2299 O3431 Maternal care for cervical incompetence, first trimester 1/1/2021 12/31/2299 O3432 Maternal care for cervical incompetence, second trimester 1/1/2021 12/31/2299 O3433 Maternal care for cervical incompetence, third trimester 1/1/2021 12/31/2299 O3441 Maternal care for oth abnlt of cervix, first trimester 1/1/2021 12/31/2299 O3442 Maternal care for oth abnlt of cervix, second trimester 1/1/2021 12/31/2299 O3443 Maternal care for oth abnlt of cervix, third trimester 1/1/2021 12/31/2299 O34511 Maternal care for incarceration of gravid uterus, first tri 1/1/2021 12/31/2299 O34512 Maternal care for incarceration of gravid uterus, second tri 1/1/2021 12/31/2299 O34513 Maternal care for incarceration of gravid uterus, third tri 1/1/2021 12/31/2299 O34521 Maternal care for prolapse of gravid uterus, first trimester 1/1/2021 12/31/2299 O34522 Maternal care for prolapse of gravid uterus, second tri 1/1/2021 12/31/2299 O34523 Maternal care for prolapse of gravid uterus, third trimester 1/1/2021 12/31/2299
178 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O34531 Maternal care for retroversion of gravid uterus, first tri 1/1/2021 12/31/2299 O34532 Maternal care for retroversion of gravid uterus, second tri 1/1/2021 12/31/2299 O34533 Maternal care for retroversion of gravid uterus, third tri 1/1/2021 12/31/2299 O34591 Maternal care for oth abnlt of gravid uterus, first tri 1/1/2021 12/31/2299 O34592 Maternal care for oth abnlt of gravid uterus, second tri 1/1/2021 12/31/2299 O34593 Maternal care for oth abnlt of gravid uterus, third tri 1/1/2021 12/31/2299 O3461 Maternal care for abnormality of vagina, first trimester 1/1/2021 12/31/2299 O3462 Maternal care for abnormality of vagina, second trimester 1/1/2021 12/31/2299 O3463 Maternal care for abnormality of vagina, third trimester 1/1/2021 12/31/2299 O3471 Maternal care for abnlt of vulva and perineum, first tri 1/1/2021 12/31/2299 O3472 Maternal care for abnlt of vulva and perineum, second tri 1/1/2021 12/31/2299 O3473 Maternal care for abnlt of vulva and perineum, third tri 1/1/2021 12/31/2299 O3481 Maternal care for oth abnlt of pelvic organs, first tri 1/1/2021 12/31/2299 O3482 Maternal care for oth abnlt of pelvic organs, second tri 1/1/2021 12/31/2299 O3483 Maternal care for oth abnlt of pelvic organs, third tri 1/1/2021 12/31/2299 O3491 Maternal care for abnlt of pelvic organ, unsp, first tri 1/1/2021 12/31/2299 O3492 Maternal care for abnlt of pelvic organ, unsp, second tri 1/1/2021 12/31/2299 O3493 Maternal care for abnlt of pelvic organ, unsp, third tri 1/1/2021 12/31/2299 O350XX0 Maternal care for (suspected) cnsl malform in fetus, unsp 1/1/2021 12/31/2299 O350XX1 Maternal care for (suspected) cnsl malform in fetus, fetus 1 1/1/2021 12/31/2299 O350XX2 Maternal care for (suspected) cnsl malform in fetus, fetus 2 1/1/2021 12/31/2299 O350XX3 Maternal care for (suspected) cnsl malform in fetus, fetus 3 1/1/2021 12/31/2299 O350XX4 Maternal care for (suspected) cnsl malform in fetus, fetus 4 1/1/2021 12/31/2299 O350XX5 Maternal care for (suspected) cnsl malform in fetus, fetus 5 1/1/2021 12/31/2299 O350XX9 Maternal care for (suspected) cnsl malform in fetus, oth 1/1/2021 12/31/2299 O351XX0 Maternal care for chromosomal abnormality in fetus, unsp 1/1/2021 12/31/2299 O351XX1 Maternal care for chromosomal abnormality in fetus, fetus 1 1/1/2021 12/31/2299 O351XX2 Maternal care for chromosomal abnormality in fetus, fetus 2 1/1/2021 12/31/2299 O351XX3 Maternal care for chromosomal abnormality in fetus, fetus 3 1/1/2021 12/31/2299 O351XX4 Maternal care for chromosomal abnormality in fetus, fetus 4 1/1/2021 12/31/2299 O351XX5 Maternal care for chromosomal abnormality in fetus, fetus 5 1/1/2021 12/31/2299 O351XX9 Maternal care for chromosomal abnormality in fetus, oth 1/1/2021 12/31/2299
179 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O352XX0 Maternal care for hereditary disease in fetus, unsp 1/1/2021 12/31/2299 O352XX1 Maternal care for hereditary disease in fetus, fetus 1 1/1/2021 12/31/2299 O352XX2 Maternal care for hereditary disease in fetus, fetus 2 1/1/2021 12/31/2299 O352XX3 Maternal care for hereditary disease in fetus, fetus 3 1/1/2021 12/31/2299 O352XX4 Maternal care for hereditary disease in fetus, fetus 4 1/1/2021 12/31/2299 O352XX5 Maternal care for hereditary disease in fetus, fetus 5 1/1/2021 12/31/2299 O352XX9 Maternal care for hereditary disease in fetus, oth 1/1/2021 12/31/2299 O353XX0 Matern care for damag to fts from viral dis in mother, unsp 1/1/2021 12/31/2299 O353XX1 Matern care for damag to fts from viral dis in mother, fts1 1/1/2021 12/31/2299 O353XX2 Matern care for damag to fts from viral dis in mother, fts2 1/1/2021 12/31/2299 O353XX3 Matern care for damag to fts from viral dis in mother, fts3 1/1/2021 12/31/2299 O353XX4 Matern care for damag to fts from viral dis in mother, fts4 1/1/2021 12/31/2299 O353XX5 Matern care for damag to fts from viral dis in mother, fts5 1/1/2021 12/31/2299 O353XX9 Matern care for damag to fetus from viral dis in mother, oth 1/1/2021 12/31/2299 O354XX0 Maternal care for damage to fetus from alcohol, unsp 1/1/2021 12/31/2299 O354XX1 Maternal care for damage to fetus from alcohol, fetus 1 1/1/2021 12/31/2299 O354XX2 Maternal care for damage to fetus from alcohol, fetus 2 1/1/2021 12/31/2299 O354XX3 Maternal care for damage to fetus from alcohol, fetus 3 1/1/2021 12/31/2299 O354XX4 Maternal care for damage to fetus from alcohol, fetus 4 1/1/2021 12/31/2299 O354XX5 Maternal care for damage to fetus from alcohol, fetus 5 1/1/2021 12/31/2299 O354XX9 Maternal care for damage to fetus from alcohol, oth 1/1/2021 12/31/2299 O355XX0 Maternal care for (suspected) damage to fetus by drugs, unsp 1/1/2021 12/31/2299 O355XX1 Maternal care for damage to fetus by drugs, fetus 1 1/1/2021 12/31/2299 O355XX2 Maternal care for damage to fetus by drugs, fetus 2 1/1/2021 12/31/2299 O355XX3 Maternal care for damage to fetus by drugs, fetus 3 1/1/2021 12/31/2299 O355XX4 Maternal care for damage to fetus by drugs, fetus 4 1/1/2021 12/31/2299 O355XX5 Maternal care for damage to fetus by drugs, fetus 5 1/1/2021 12/31/2299 O355XX9 Maternal care for (suspected) damage to fetus by drugs, oth 1/1/2021 12/31/2299 O356XX0 Maternal care for damage to fetus by radiation, unsp 1/1/2021 12/31/2299 O356XX1 Maternal care for damage to fetus by radiation, fetus 1 1/1/2021 12/31/2299 O356XX2 Maternal care for damage to fetus by radiation, fetus 2 1/1/2021 12/31/2299 O356XX3 Maternal care for damage to fetus by radiation, fetus 3 1/1/2021 12/31/2299
180 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O356XX4 Maternal care for damage to fetus by radiation, fetus 4 1/1/2021 12/31/2299 O356XX5 Maternal care for damage to fetus by radiation, fetus 5 1/1/2021 12/31/2299 O356XX9 Maternal care for damage to fetus by radiation, oth 1/1/2021 12/31/2299 O358XX0 Maternal care for oth fetal abnormality and damage, unsp 1/1/2021 12/31/2299 O358XX1 Maternal care for oth fetal abnormality and damage, fetus 1 1/1/2021 12/31/2299 O358XX2 Maternal care for oth fetal abnormality and damage, fetus 2 1/1/2021 12/31/2299 O358XX3 Maternal care for oth fetal abnormality and damage, fetus 3 1/1/2021 12/31/2299 O358XX4 Maternal care for oth fetal abnormality and damage, fetus 4 1/1/2021 12/31/2299 O358XX5 Maternal care for oth fetal abnormality and damage, fetus 5 1/1/2021 12/31/2299 O358XX9 Maternal care for oth fetal abnormality and damage, oth 1/1/2021 12/31/2299 O359XX0 Maternal care for fetal abnormality and damage, unsp, unsp 1/1/2021 12/31/2299 O359XX1 Maternal care for fetal abnlt and damage, unsp, fetus 1 1/1/2021 12/31/2299 O359XX2 Maternal care for fetal abnlt and damage, unsp, fetus 2 1/1/2021 12/31/2299 O359XX3 Maternal care for fetal abnlt and damage, unsp, fetus 3 1/1/2021 12/31/2299 O359XX4 Maternal care for fetal abnlt and damage, unsp, fetus 4 1/1/2021 12/31/2299 O359XX5 Maternal care for fetal abnlt and damage, unsp, fetus 5 1/1/2021 12/31/2299 O359XX9 Maternal care for fetal abnormality and damage, unsp, oth 1/1/2021 12/31/2299 O360110 Maternal care for anti-D antibodies, first trimester, unsp 1/1/2021 12/31/2299 O360111 Maternal care for anti-D antibodies, first tri, fetus 1 1/1/2021 12/31/2299 O360112 Maternal care for anti-D antibodies, first tri, fetus 2 1/1/2021 12/31/2299 O360113 Maternal care for anti-D antibodies, first tri, fetus 3 1/1/2021 12/31/2299 O360114 Maternal care for anti-D antibodies, first tri, fetus 4 1/1/2021 12/31/2299 O360115 Maternal care for anti-D antibodies, first tri, fetus 5 1/1/2021 12/31/2299 O360119 Maternal care for anti-D antibodies, first trimester, oth 1/1/2021 12/31/2299 O360120 Maternal care for anti-D antibodies, second trimester, unsp 1/1/2021 12/31/2299 O360121 Maternal care for anti-D antibodies, second tri, fetus 1 1/1/2021 12/31/2299 O360122 Maternal care for anti-D antibodies, second tri, fetus 2 1/1/2021 12/31/2299 O360123 Maternal care for anti-D antibodies, second tri, fetus 3 1/1/2021 12/31/2299 O360124 Maternal care for anti-D antibodies, second tri, fetus 4 1/1/2021 12/31/2299 O360125 Maternal care for anti-D antibodies, second tri, fetus 5 1/1/2021 12/31/2299 O360129 Maternal care for anti-D antibodies, second trimester, oth 1/1/2021 12/31/2299 O360130 Maternal care for anti-D antibodies, third trimester, unsp 1/1/2021 12/31/2299
181 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O360131 Maternal care for anti-D antibodies, third tri, fetus 1 1/1/2021 12/31/2299 O360132 Maternal care for anti-D antibodies, third tri, fetus 2 1/1/2021 12/31/2299 O360133 Maternal care for anti-D antibodies, third tri, fetus 3 1/1/2021 12/31/2299 O360134 Maternal care for anti-D antibodies, third tri, fetus 4 1/1/2021 12/31/2299 O360135 Maternal care for anti-D antibodies, third tri, fetus 5 1/1/2021 12/31/2299 O360139 Maternal care for anti-D antibodies, third trimester, oth 1/1/2021 12/31/2299 O360910 Maternal care for oth rhesus isoimmun, first trimester, unsp 1/1/2021 12/31/2299 O360911 Maternal care for oth rhesus isoimmun, first tri, fetus 1 1/1/2021 12/31/2299 O360912 Maternal care for oth rhesus isoimmun, first tri, fetus 2 1/1/2021 12/31/2299 O360913 Maternal care for oth rhesus isoimmun, first tri, fetus 3 1/1/2021 12/31/2299 O360914 Maternal care for oth rhesus isoimmun, first tri, fetus 4 1/1/2021 12/31/2299 O360915 Maternal care for oth rhesus isoimmun, first tri, fetus 5 1/1/2021 12/31/2299 O360919 Maternal care for oth rhesus isoimmun, first trimester, oth 1/1/2021 12/31/2299 O360920 Maternal care for oth rhesus isoimmun, second tri, unsp 1/1/2021 12/31/2299 O360921 Maternal care for oth rhesus isoimmun, second tri, fetus 1 1/1/2021 12/31/2299 O360922 Maternal care for oth rhesus isoimmun, second tri, fetus 2 1/1/2021 12/31/2299 O360923 Maternal care for oth rhesus isoimmun, second tri, fetus 3 1/1/2021 12/31/2299 O360924 Maternal care for oth rhesus isoimmun, second tri, fetus 4 1/1/2021 12/31/2299 O360925 Maternal care for oth rhesus isoimmun, second tri, fetus 5 1/1/2021 12/31/2299 O360929 Maternal care for oth rhesus isoimmun, second trimester, oth 1/1/2021 12/31/2299 O360930 Maternal care for oth rhesus isoimmun, third trimester, unsp 1/1/2021 12/31/2299 O360931 Maternal care for oth rhesus isoimmun, third tri, fetus 1 1/1/2021 12/31/2299 O360932 Maternal care for oth rhesus isoimmun, third tri, fetus 2 1/1/2021 12/31/2299 O360933 Maternal care for oth rhesus isoimmun, third tri, fetus 3 1/1/2021 12/31/2299 O360934 Maternal care for oth rhesus isoimmun, third tri, fetus 4 1/1/2021 12/31/2299 O360935 Maternal care for oth rhesus isoimmun, third tri, fetus 5 1/1/2021 12/31/2299 O360939 Maternal care for oth rhesus isoimmun, third trimester, oth 1/1/2021 12/31/2299 O361110 Maternal care for Anti-A sensitization, first tri, unsp 1/1/2021 12/31/2299 O361111 Maternal care for Anti-A sensitization, first tri, fetus 1 1/1/2021 12/31/2299 O361112 Maternal care for Anti-A sensitization, first tri, fetus 2 1/1/2021 12/31/2299 O361113 Maternal care for Anti-A sensitization, first tri, fetus 3 1/1/2021 12/31/2299 O361114 Maternal care for Anti-A sensitization, first tri, fetus 4 1/1/2021 12/31/2299
182 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O361115 Maternal care for Anti-A sensitization, first tri, fetus 5 1/1/2021 12/31/2299 O361119 Maternal care for Anti-A sensitization, first trimester, oth 1/1/2021 12/31/2299 O361120 Maternal care for Anti-A sensitization, second tri, unsp 1/1/2021 12/31/2299 O361121 Maternal care for Anti-A sensitization, second tri, fetus 1 1/1/2021 12/31/2299 O361122 Maternal care for Anti-A sensitization, second tri, fetus 2 1/1/2021 12/31/2299 O361123 Maternal care for Anti-A sensitization, second tri, fetus 3 1/1/2021 12/31/2299 O361124 Maternal care for Anti-A sensitization, second tri, fetus 4 1/1/2021 12/31/2299 O361125 Maternal care for Anti-A sensitization, second tri, fetus 5 1/1/2021 12/31/2299 O361129 Maternal care for Anti-A sensitization, second tri, oth 1/1/2021 12/31/2299 O361130 Maternal care for Anti-A sensitization, third tri, unsp 1/1/2021 12/31/2299 O361131 Maternal care for Anti-A sensitization, third tri, fetus 1 1/1/2021 12/31/2299 O361132 Maternal care for Anti-A sensitization, third tri, fetus 2 1/1/2021 12/31/2299 O361133 Maternal care for Anti-A sensitization, third tri, fetus 3 1/1/2021 12/31/2299 O361134 Maternal care for Anti-A sensitization, third tri, fetus 4 1/1/2021 12/31/2299 O361135 Maternal care for Anti-A sensitization, third tri, fetus 5 1/1/2021 12/31/2299 O361139 Maternal care for Anti-A sensitization, third trimester, oth 1/1/2021 12/31/2299 O361910 Maternal care for oth isoimmunization, first trimester, unsp 1/1/2021 12/31/2299 O361911 Maternal care for oth isoimmun, first trimester, fetus 1 1/1/2021 12/31/2299 O361912 Maternal care for oth isoimmun, first trimester, fetus 2 1/1/2021 12/31/2299 O361913 Maternal care for oth isoimmun, first trimester, fetus 3 1/1/2021 12/31/2299 O361914 Maternal care for oth isoimmun, first trimester, fetus 4 1/1/2021 12/31/2299 O361915 Maternal care for oth isoimmun, first trimester, fetus 5 1/1/2021 12/31/2299 O361919 Maternal care for oth isoimmunization, first trimester, oth 1/1/2021 12/31/2299 O361920 Maternal care for oth isoimmun, second trimester, unsp 1/1/2021 12/31/2299 O361921 Maternal care for oth isoimmun, second trimester, fetus 1 1/1/2021 12/31/2299 O361922 Maternal care for oth isoimmun, second trimester, fetus 2 1/1/2021 12/31/2299 O361923 Maternal care for oth isoimmun, second trimester, fetus 3 1/1/2021 12/31/2299 O361924 Maternal care for oth isoimmun, second trimester, fetus 4 1/1/2021 12/31/2299 O361925 Maternal care for oth isoimmun, second trimester, fetus 5 1/1/2021 12/31/2299 O361929 Maternal care for oth isoimmunization, second trimester, oth 1/1/2021 12/31/2299 O361930 Maternal care for oth isoimmunization, third trimester, unsp 1/1/2021 12/31/2299 O361931 Maternal care for oth isoimmun, third trimester, fetus 1 1/1/2021 12/31/2299
183 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O361932 Maternal care for oth isoimmun, third trimester, fetus 2 1/1/2021 12/31/2299 O361933 Maternal care for oth isoimmun, third trimester, fetus 3 1/1/2021 12/31/2299 O361934 Maternal care for oth isoimmun, third trimester, fetus 4 1/1/2021 12/31/2299 O361935 Maternal care for oth isoimmun, third trimester, fetus 5 1/1/2021 12/31/2299 O361939 Maternal care for oth isoimmunization, third trimester, oth 1/1/2021 12/31/2299 O3621X0 Maternal care for hydrops fetalis, first trimester, unsp 1/1/2021 12/31/2299 O3621X1 Maternal care for hydrops fetalis, first trimester, fetus 1 1/1/2021 12/31/2299 O3621X2 Maternal care for hydrops fetalis, first trimester, fetus 2 1/1/2021 12/31/2299 O3621X3 Maternal care for hydrops fetalis, first trimester, fetus 3 1/1/2021 12/31/2299 O3621X4 Maternal care for hydrops fetalis, first trimester, fetus 4 1/1/2021 12/31/2299 O3621X5 Maternal care for hydrops fetalis, first trimester, fetus 5 1/1/2021 12/31/2299 O3621X9 Maternal care for hydrops fetalis, first trimester, oth 1/1/2021 12/31/2299 O3622X0 Maternal care for hydrops fetalis, second trimester, unsp 1/1/2021 12/31/2299 O3622X1 Maternal care for hydrops fetalis, second trimester, fetus 1 1/1/2021 12/31/2299 O3622X2 Maternal care for hydrops fetalis, second trimester, fetus 2 1/1/2021 12/31/2299 O3622X3 Maternal care for hydrops fetalis, second trimester, fetus 3 1/1/2021 12/31/2299 O3622X4 Maternal care for hydrops fetalis, second trimester, fetus 4 1/1/2021 12/31/2299 O3622X5 Maternal care for hydrops fetalis, second trimester, fetus 5 1/1/2021 12/31/2299 O3622X9 Maternal care for hydrops fetalis, second trimester, oth 1/1/2021 12/31/2299 O3623X0 Maternal care for hydrops fetalis, third trimester, unsp 1/1/2021 12/31/2299 O3623X1 Maternal care for hydrops fetalis, third trimester, fetus 1 1/1/2021 12/31/2299 O3623X2 Maternal care for hydrops fetalis, third trimester, fetus 2 1/1/2021 12/31/2299 O3623X3 Maternal care for hydrops fetalis, third trimester, fetus 3 1/1/2021 12/31/2299 O3623X4 Maternal care for hydrops fetalis, third trimester, fetus 4 1/1/2021 12/31/2299 O3623X5 Maternal care for hydrops fetalis, third trimester, fetus 5 1/1/2021 12/31/2299 O3623X9 Maternal care for hydrops fetalis, third trimester, oth 1/1/2021 12/31/2299 O364XX0 Maternal care for intrauterine death, not applicable or unsp 1/1/2021 12/31/2299 O364XX1 Maternal care for intrauterine death, fetus 1 1/1/2021 12/31/2299 O364XX2 Maternal care for intrauterine death, fetus 2 1/1/2021 12/31/2299 O364XX3 Maternal care for intrauterine death, fetus 3 1/1/2021 12/31/2299 O364XX4 Maternal care for intrauterine death, fetus 4 1/1/2021 12/31/2299 O364XX5 Maternal care for intrauterine death, fetus 5 1/1/2021 12/31/2299
184 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O364XX9 Maternal care for intrauterine death, other fetus 1/1/2021 12/31/2299 O365110 Matern care for known or susp placntl insuff, 1st tri, unsp 1/1/2021 12/31/2299 O365111 Matern care for known or susp placntl insuff, 1st tri, fts1 1/1/2021 12/31/2299 O365112 Matern care for known or susp placntl insuff, 1st tri, fts2 1/1/2021 12/31/2299 O365113 Matern care for known or susp placntl insuff, 1st tri, fts3 1/1/2021 12/31/2299 O365114 Matern care for known or susp placntl insuff, 1st tri, fts4 1/1/2021 12/31/2299 O365115 Matern care for known or susp placntl insuff, 1st tri, fts5 1/1/2021 12/31/2299 O365119 Matern care for known or susp placntl insuff, first tri, oth 1/1/2021 12/31/2299 O365120 Matern care for known or susp placntl insuff, 2nd tri, unsp 1/1/2021 12/31/2299 O365121 Matern care for known or susp placntl insuff, 2nd tri, fts1 1/1/2021 12/31/2299 O365122 Matern care for known or susp placntl insuff, 2nd tri, fts2 1/1/2021 12/31/2299 O365123 Matern care for known or susp placntl insuff, 2nd tri, fts3 1/1/2021 12/31/2299 O365124 Matern care for known or susp placntl insuff, 2nd tri, fts4 1/1/2021 12/31/2299 O365125 Matern care for known or susp placntl insuff, 2nd tri, fts5 1/1/2021 12/31/2299 O365129 Matern care for known or susp placntl insuff, 2nd tri, oth 1/1/2021 12/31/2299 O365130 Matern care for or susp placntl insuff, third tri, unsp 1/1/2021 12/31/2299 O365131 Matern care for or susp placntl insuff, third tri, fts1 1/1/2021 12/31/2299 O365132 Matern care for or susp placntl insuff, third tri, fts2 1/1/2021 12/31/2299 O365133 Matern care for or susp placntl insuff, third tri, fts3 1/1/2021 12/31/2299 O365134 Matern care for or susp placntl insuff, third tri, fts4 1/1/2021 12/31/2299 O365135 Matern care for or susp placntl insuff, third tri, fts5 1/1/2021 12/31/2299 O365139 Matern care for known or susp placntl insuff, third tri, oth 1/1/2021 12/31/2299 O365910 Matern care for oth or susp poor fetl grth, 1st tri, unsp 1/1/2021 12/31/2299 O365911 Matern care for oth or susp poor fetl grth, 1st tri, fts1 1/1/2021 12/31/2299 O365912 Matern care for oth or susp poor fetl grth, 1st tri, fts2 1/1/2021 12/31/2299 O365913 Matern care for oth or susp poor fetl grth, 1st tri, fts3 1/1/2021 12/31/2299 O365914 Matern care for oth or susp poor fetl grth, 1st tri, fts4 1/1/2021 12/31/2299 O365915 Matern care for oth or susp poor fetl grth, 1st tri, fts5 1/1/2021 12/31/2299 O365919 Matern care for oth or susp poor fetl grth, 1st tri, oth 1/1/2021 12/31/2299 O365920 Matern care for oth or susp poor fetl grth, 2nd tri, unsp 1/1/2021 12/31/2299 O365921 Matern care for oth or susp poor fetl grth, 2nd tri, fts1 1/1/2021 12/31/2299 O365922 Matern care for oth or susp poor fetl grth, 2nd tri, fts2 1/1/2021 12/31/2299
185 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O365923 Matern care for oth or susp poor fetl grth, 2nd tri, fts3 1/1/2021 12/31/2299 O365924 Matern care for oth or susp poor fetl grth, 2nd tri, fts4 1/1/2021 12/31/2299 O365925 Matern care for oth or susp poor fetl grth, 2nd tri, fts5 1/1/2021 12/31/2299 O365929 Matern care for oth or susp poor fetl grth, 2nd tri, oth 1/1/2021 12/31/2299 O365930 Matern care for oth or susp poor fetl grth, third tri, unsp 1/1/2021 12/31/2299 O365931 Matern care for oth or susp poor fetl grth, third tri, fts1 1/1/2021 12/31/2299 O365932 Matern care for oth or susp poor fetl grth, third tri, fts2 1/1/2021 12/31/2299 O365933 Matern care for oth or susp poor fetl grth, third tri, fts3 1/1/2021 12/31/2299 O365934 Matern care for oth or susp poor fetl grth, third tri, fts4 1/1/2021 12/31/2299 O365935 Matern care for oth or susp poor fetl grth, third tri, fts5 1/1/2021 12/31/2299 O365939 Matern care for oth or susp poor fetl grth, third tri, oth 1/1/2021 12/31/2299 O3661X0 Maternal care for excess fetal growth, first trimester, unsp 1/1/2021 12/31/2299 O3661X1 Maternal care for excess fetal growth, first tri, fetus 1 1/1/2021 12/31/2299 O3661X2 Maternal care for excess fetal growth, first tri, fetus 2 1/1/2021 12/31/2299 O3661X3 Maternal care for excess fetal growth, first tri, fetus 3 1/1/2021 12/31/2299 O3661X4 Maternal care for excess fetal growth, first tri, fetus 4 1/1/2021 12/31/2299 O3661X5 Maternal care for excess fetal growth, first tri, fetus 5 1/1/2021 12/31/2299 O3661X9 Maternal care for excess fetal growth, first trimester, oth 1/1/2021 12/31/2299 O3662X0 Maternal care for excess fetal growth, second tri, unsp 1/1/2021 12/31/2299 O3662X1 Maternal care for excess fetal growth, second tri, fetus 1 1/1/2021 12/31/2299 O3662X2 Maternal care for excess fetal growth, second tri, fetus 2 1/1/2021 12/31/2299 O3662X3 Maternal care for excess fetal growth, second tri, fetus 3 1/1/2021 12/31/2299 O3662X4 Maternal care for excess fetal growth, second tri, fetus 4 1/1/2021 12/31/2299 O3662X5 Maternal care for excess fetal growth, second tri, fetus 5 1/1/2021 12/31/2299 O3662X9 Maternal care for excess fetal growth, second trimester, oth 1/1/2021 12/31/2299 O3663X0 Maternal care for excess fetal growth, third trimester, unsp 1/1/2021 12/31/2299 O3663X1 Maternal care for excess fetal growth, third tri, fetus 1 1/1/2021 12/31/2299 O3663X2 Maternal care for excess fetal growth, third tri, fetus 2 1/1/2021 12/31/2299 O3663X3 Maternal care for excess fetal growth, third tri, fetus 3 1/1/2021 12/31/2299 O3663X4 Maternal care for excess fetal growth, third tri, fetus 4 1/1/2021 12/31/2299 O3663X5 Maternal care for excess fetal growth, third tri, fetus 5 1/1/2021 12/31/2299 O3663X9 Maternal care for excess fetal growth, third trimester, oth 1/1/2021 12/31/2299
186 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O3671X0 Maternal care for viable fetus in abd preg, first tri, unsp 1/1/2021 12/31/2299 O3671X1 Matern care for viable fetus in abd preg, first tri, fetus 1 1/1/2021 12/31/2299 O3671X2 Matern care for viable fetus in abd preg, first tri, fetus 2 1/1/2021 12/31/2299 O3671X3 Matern care for viable fetus in abd preg, first tri, fetus 3 1/1/2021 12/31/2299 O3671X4 Matern care for viable fetus in abd preg, first tri, fetus 4 1/1/2021 12/31/2299 O3671X5 Matern care for viable fetus in abd preg, first tri, fetus 5 1/1/2021 12/31/2299 O3671X9 Maternal care for viable fetus in abd preg, first tri, oth 1/1/2021 12/31/2299 O3672X0 Maternal care for viable fetus in abd preg, second tri, unsp 1/1/2021 12/31/2299 O3672X1 Matern care for viable fetus in abd preg, second tri, fts1 1/1/2021 12/31/2299 O3672X2 Matern care for viable fetus in abd preg, second tri, fts2 1/1/2021 12/31/2299 O3672X3 Matern care for viable fetus in abd preg, second tri, fts3 1/1/2021 12/31/2299 O3672X4 Matern care for viable fetus in abd preg, second tri, fts4 1/1/2021 12/31/2299 O3672X5 Matern care for viable fetus in abd preg, second tri, fts5 1/1/2021 12/31/2299 O3672X9 Maternal care for viable fetus in abd preg, second tri, oth 1/1/2021 12/31/2299 O3673X0 Maternal care for viable fetus in abd preg, third tri, unsp 1/1/2021 12/31/2299 O3673X1 Matern care for viable fetus in abd preg, third tri, fetus 1 1/1/2021 12/31/2299 O3673X2 Matern care for viable fetus in abd preg, third tri, fetus 2 1/1/2021 12/31/2299 O3673X3 Matern care for viable fetus in abd preg, third tri, fetus 3 1/1/2021 12/31/2299 O3673X4 Matern care for viable fetus in abd preg, third tri, fetus 4 1/1/2021 12/31/2299 O3673X5 Matern care for viable fetus in abd preg, third tri, fetus 5 1/1/2021 12/31/2299 O3673X9 Maternal care for viable fetus in abd preg, third tri, oth 1/1/2021 12/31/2299 O3680X0 Pregnancy w inconclusive fetal viability, unsp 1/1/2021 12/31/2299 O3680X1 Pregnancy with inconclusive fetal viability, fetus 1 1/1/2021 12/31/2299 O3680X2 Pregnancy with inconclusive fetal viability, fetus 2 1/1/2021 12/31/2299 O3680X3 Pregnancy with inconclusive fetal viability, fetus 3 1/1/2021 12/31/2299 O3680X4 Pregnancy with inconclusive fetal viability, fetus 4 1/1/2021 12/31/2299 O3680X5 Pregnancy with inconclusive fetal viability, fetus 5 1/1/2021 12/31/2299 O3680X9 Pregnancy with inconclusive fetal viability, other fetus 1/1/2021 12/31/2299 O368120 Decreased fetal movements, second trimester, unsp 1/1/2021 12/31/2299 O368121 Decreased fetal movements, second trimester, fetus 1 1/1/2021 12/31/2299 O368122 Decreased fetal movements, second trimester, fetus 2 1/1/2021 12/31/2299 O368123 Decreased fetal movements, second trimester, fetus 3 1/1/2021 12/31/2299
187 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O368124 Decreased fetal movements, second trimester, fetus 4 1/1/2021 12/31/2299 O368125 Decreased fetal movements, second trimester, fetus 5 1/1/2021 12/31/2299 O368129 Decreased fetal movements, second trimester, other fetus 1/1/2021 12/31/2299 O368130 Decreased fetal movements, third trimester, unsp 1/1/2021 12/31/2299 O368131 Decreased fetal movements, third trimester, fetus 1 1/1/2021 12/31/2299 O368132 Decreased fetal movements, third trimester, fetus 2 1/1/2021 12/31/2299 O368133 Decreased fetal movements, third trimester, fetus 3 1/1/2021 12/31/2299 O368134 Decreased fetal movements, third trimester, fetus 4 1/1/2021 12/31/2299 O368135 Decreased fetal movements, third trimester, fetus 5 1/1/2021 12/31/2299 O368139 Decreased fetal movements, third trimester, other fetus 1/1/2021 12/31/2299 O368190 Decreased fetal movements, unsp trimester, unsp 1/1/2021 12/31/2299 O368191 Decreased fetal movements, unspecified trimester, fetus 1 1/1/2021 12/31/2299 O368192 Decreased fetal movements, unspecified trimester, fetus 2 1/1/2021 12/31/2299 O368193 Decreased fetal movements, unspecified trimester, fetus 3 1/1/2021 12/31/2299 O368194 Decreased fetal movements, unspecified trimester, fetus 4 1/1/2021 12/31/2299 O368195 Decreased fetal movements, unspecified trimester, fetus 5 1/1/2021 12/31/2299 O368199 Decreased fetal movements, unsp trimester, other fetus 1/1/2021 12/31/2299 O368910 Maternal care for oth fetal problems, first trimester, unsp 1/1/2021 12/31/2299 O368911 Maternal care for oth fetal problems, first tri, fetus 1 1/1/2021 12/31/2299 O368912 Maternal care for oth fetal problems, first tri, fetus 2 1/1/2021 12/31/2299 O368913 Maternal care for oth fetal problems, first tri, fetus 3 1/1/2021 12/31/2299 O368914 Maternal care for oth fetal problems, first tri, fetus 4 1/1/2021 12/31/2299 O368915 Maternal care for oth fetal problems, first tri, fetus 5 1/1/2021 12/31/2299 O368919 Maternal care for oth fetal problems, first trimester, oth 1/1/2021 12/31/2299 O368920 Maternal care for oth fetal problems, second trimester, unsp 1/1/2021 12/31/2299 O368921 Maternal care for oth fetal problems, second tri, fetus 1 1/1/2021 12/31/2299 O368922 Maternal care for oth fetal problems, second tri, fetus 2 1/1/2021 12/31/2299 O368923 Maternal care for oth fetal problems, second tri, fetus 3 1/1/2021 12/31/2299 O368924 Maternal care for oth fetal problems, second tri, fetus 4 1/1/2021 12/31/2299 O368925 Maternal care for oth fetal problems, second tri, fetus 5 1/1/2021 12/31/2299 O368929 Maternal care for oth fetal problems, second trimester, oth 1/1/2021 12/31/2299 O368930 Maternal care for oth fetal problems, third trimester, unsp 1/1/2021 12/31/2299
188 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O368931 Maternal care for oth fetal problems, third tri, fetus 1 1/1/2021 12/31/2299 O368932 Maternal care for oth fetal problems, third tri, fetus 2 1/1/2021 12/31/2299 O368933 Maternal care for oth fetal problems, third tri, fetus 3 1/1/2021 12/31/2299 O368934 Maternal care for oth fetal problems, third tri, fetus 4 1/1/2021 12/31/2299 O368935 Maternal care for oth fetal problems, third tri, fetus 5 1/1/2021 12/31/2299 O368939 Maternal care for oth fetal problems, third trimester, oth 1/1/2021 12/31/2299 O3691X0 Maternal care for fetal problem, unsp, first trimester, unsp 1/1/2021 12/31/2299 O3691X1 Maternal care for fetal problem, unsp, first tri, fetus 1 1/1/2021 12/31/2299 O3691X2 Maternal care for fetal problem, unsp, first tri, fetus 2 1/1/2021 12/31/2299 O3691X3 Maternal care for fetal problem, unsp, first tri, fetus 3 1/1/2021 12/31/2299 O3691X4 Maternal care for fetal problem, unsp, first tri, fetus 4 1/1/2021 12/31/2299 O3691X5 Maternal care for fetal problem, unsp, first tri, fetus 5 1/1/2021 12/31/2299 O3691X9 Maternal care for fetal problem, unsp, first trimester, oth 1/1/2021 12/31/2299 O3692X0 Maternal care for fetal problem, unsp, second tri, unsp 1/1/2021 12/31/2299 O3692X1 Maternal care for fetal problem, unsp, second tri, fetus 1 1/1/2021 12/31/2299 O3692X2 Maternal care for fetal problem, unsp, second tri, fetus 2 1/1/2021 12/31/2299 O3692X3 Maternal care for fetal problem, unsp, second tri, fetus 3 1/1/2021 12/31/2299 O3692X4 Maternal care for fetal problem, unsp, second tri, fetus 4 1/1/2021 12/31/2299 O3692X5 Maternal care for fetal problem, unsp, second tri, fetus 5 1/1/2021 12/31/2299 O3692X9 Maternal care for fetal problem, unsp, second trimester, oth 1/1/2021 12/31/2299 O3693X0 Maternal care for fetal problem, unsp, third trimester, unsp 1/1/2021 12/31/2299 O3693X1 Maternal care for fetal problem, unsp, third tri, fetus 1 1/1/2021 12/31/2299 O3693X2 Maternal care for fetal problem, unsp, third tri, fetus 2 1/1/2021 12/31/2299 O3693X3 Maternal care for fetal problem, unsp, third tri, fetus 3 1/1/2021 12/31/2299 O3693X4 Maternal care for fetal problem, unsp, third tri, fetus 4 1/1/2021 12/31/2299 O3693X5 Maternal care for fetal problem, unsp, third tri, fetus 5 1/1/2021 12/31/2299 O3693X9 Maternal care for fetal problem, unsp, third trimester, oth 1/1/2021 12/31/2299 O401XX0 Polyhydramnios, first trimester, not applicable or unsp 1/1/2021 12/31/2299 O401XX1 Polyhydramnios, first trimester, fetus 1 1/1/2021 12/31/2299 O401XX2 Polyhydramnios, first trimester, fetus 2 1/1/2021 12/31/2299 O401XX3 Polyhydramnios, first trimester, fetus 3 1/1/2021 12/31/2299 O401XX4 Polyhydramnios, first trimester, fetus 4 1/1/2021 12/31/2299
189 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O401XX5 Polyhydramnios, first trimester, fetus 5 1/1/2021 12/31/2299 O401XX9 Polyhydramnios, first trimester, other fetus 1/1/2021 12/31/2299 O402XX0 Polyhydramnios, second trimester, not applicable or unsp 1/1/2021 12/31/2299 O402XX1 Polyhydramnios, second trimester, fetus 1 1/1/2021 12/31/2299 O402XX2 Polyhydramnios, second trimester, fetus 2 1/1/2021 12/31/2299 O402XX3 Polyhydramnios, second trimester, fetus 3 1/1/2021 12/31/2299 O402XX4 Polyhydramnios, second trimester, fetus 4 1/1/2021 12/31/2299 O402XX5 Polyhydramnios, second trimester, fetus 5 1/1/2021 12/31/2299 O402XX9 Polyhydramnios, second trimester, other fetus 1/1/2021 12/31/2299 O403XX0 Polyhydramnios, third trimester, not applicable or unsp 1/1/2021 12/31/2299 O403XX1 Polyhydramnios, third trimester, fetus 1 1/1/2021 12/31/2299 O403XX2 Polyhydramnios, third trimester, fetus 2 1/1/2021 12/31/2299 O403XX3 Polyhydramnios, third trimester, fetus 3 1/1/2021 12/31/2299 O403XX4 Polyhydramnios, third trimester, fetus 4 1/1/2021 12/31/2299 O403XX5 Polyhydramnios, third trimester, fetus 5 1/1/2021 12/31/2299 O403XX9 Polyhydramnios, third trimester, other fetus 1/1/2021 12/31/2299 O4101X0 Oligohydramnios, first trimester, not applicable or unsp 1/1/2021 12/31/2299 O4101X1 Oligohydramnios, first trimester, fetus 1 1/1/2021 12/31/2299 O4101X2 Oligohydramnios, first trimester, fetus 2 1/1/2021 12/31/2299 O4101X3 Oligohydramnios, first trimester, fetus 3 1/1/2021 12/31/2299 O4101X4 Oligohydramnios, first trimester, fetus 4 1/1/2021 12/31/2299 O4101X5 Oligohydramnios, first trimester, fetus 5 1/1/2021 12/31/2299 O4101X9 Oligohydramnios, first trimester, other fetus 1/1/2021 12/31/2299 O4102X0 Oligohydramnios, second trimester, not applicable or unsp 1/1/2021 12/31/2299 O4102X1 Oligohydramnios, second trimester, fetus 1 1/1/2021 12/31/2299 O4102X2 Oligohydramnios, second trimester, fetus 2 1/1/2021 12/31/2299 O4102X3 Oligohydramnios, second trimester, fetus 3 1/1/2021 12/31/2299 O4102X4 Oligohydramnios, second trimester, fetus 4 1/1/2021 12/31/2299 O4102X5 Oligohydramnios, second trimester, fetus 5 1/1/2021 12/31/2299 O4102X9 Oligohydramnios, second trimester, other fetus 1/1/2021 12/31/2299 O4103X0 Oligohydramnios, third trimester, not applicable or unsp 1/1/2021 12/31/2299 O4103X1 Oligohydramnios, third trimester, fetus 1 1/1/2021 12/31/2299
190 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O4103X2 Oligohydramnios, third trimester, fetus 2 1/1/2021 12/31/2299 O4103X3 Oligohydramnios, third trimester, fetus 3 1/1/2021 12/31/2299 O4103X4 Oligohydramnios, third trimester, fetus 4 1/1/2021 12/31/2299 O4103X5 Oligohydramnios, third trimester, fetus 5 1/1/2021 12/31/2299 O4103X9 Oligohydramnios, third trimester, other fetus 1/1/2021 12/31/2299 O411010 Infct of amniotic sac and membrns, unsp, first tri, unsp 1/1/2021 12/31/2299 O411011 Infct of amniotic sac and membrns, unsp, first tri, fetus 1 1/1/2021 12/31/2299 O411012 Infct of amniotic sac and membrns, unsp, first tri, fetus 2 1/1/2021 12/31/2299 O411013 Infct of amniotic sac and membrns, unsp, first tri, fetus 3 1/1/2021 12/31/2299 O411014 Infct of amniotic sac and membrns, unsp, first tri, fetus 4 1/1/2021 12/31/2299 O411015 Infct of amniotic sac and membrns, unsp, first tri, fetus 5 1/1/2021 12/31/2299 O411019 Infct of amniotic sac and membrns, unsp, first tri, oth 1/1/2021 12/31/2299 O411020 Infct of amniotic sac and membrns, unsp, second tri, unsp 1/1/2021 12/31/2299 O411021 Infct of amniotic sac and membrns, unsp, second tri, fetus 1 1/1/2021 12/31/2299 O411022 Infct of amniotic sac and membrns, unsp, second tri, fetus 2 1/1/2021 12/31/2299 O411023 Infct of amniotic sac and membrns, unsp, second tri, fetus 3 1/1/2021 12/31/2299 O411024 Infct of amniotic sac and membrns, unsp, second tri, fetus 4 1/1/2021 12/31/2299 O411025 Infct of amniotic sac and membrns, unsp, second tri, fetus 5 1/1/2021 12/31/2299 O411029 Infct of amniotic sac and membrns, unsp, second tri, oth 1/1/2021 12/31/2299 O411030 Infct of amniotic sac and membrns, unsp, third tri, unsp 1/1/2021 12/31/2299 O411031 Infct of amniotic sac and membrns, unsp, third tri, fetus 1 1/1/2021 12/31/2299 O411032 Infct of amniotic sac and membrns, unsp, third tri, fetus 2 1/1/2021 12/31/2299 O411033 Infct of amniotic sac and membrns, unsp, third tri, fetus 3 1/1/2021 12/31/2299 O411034 Infct of amniotic sac and membrns, unsp, third tri, fetus 4 1/1/2021 12/31/2299 O411035 Infct of amniotic sac and membrns, unsp, third tri, fetus 5 1/1/2021 12/31/2299 O411039 Infct of amniotic sac and membrns, unsp, third tri, oth 1/1/2021 12/31/2299 O411210 Chorioamnionitis, first trimester, not applicable or unsp 1/1/2021 12/31/2299 O411211 Chorioamnionitis, first trimester, fetus 1 1/1/2021 12/31/2299 O411212 Chorioamnionitis, first trimester, fetus 2 1/1/2021 12/31/2299 O411213 Chorioamnionitis, first trimester, fetus 3 1/1/2021 12/31/2299 O411214 Chorioamnionitis, first trimester, fetus 4 1/1/2021 12/31/2299 O411215 Chorioamnionitis, first trimester, fetus 5 1/1/2021 12/31/2299
191 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O411219 Chorioamnionitis, first trimester, other fetus 1/1/2021 12/31/2299 O411220 Chorioamnionitis, second trimester, not applicable or unsp 1/1/2021 12/31/2299 O411221 Chorioamnionitis, second trimester, fetus 1 1/1/2021 12/31/2299 O411222 Chorioamnionitis, second trimester, fetus 2 1/1/2021 12/31/2299 O411223 Chorioamnionitis, second trimester, fetus 3 1/1/2021 12/31/2299 O411224 Chorioamnionitis, second trimester, fetus 4 1/1/2021 12/31/2299 O411225 Chorioamnionitis, second trimester, fetus 5 1/1/2021 12/31/2299 O411229 Chorioamnionitis, second trimester, other fetus 1/1/2021 12/31/2299 O411230 Chorioamnionitis, third trimester, not applicable or unsp 1/1/2021 12/31/2299 O411231 Chorioamnionitis, third trimester, fetus 1 1/1/2021 12/31/2299 O411232 Chorioamnionitis, third trimester, fetus 2 1/1/2021 12/31/2299 O411233 Chorioamnionitis, third trimester, fetus 3 1/1/2021 12/31/2299 O411234 Chorioamnionitis, third trimester, fetus 4 1/1/2021 12/31/2299 O411235 Chorioamnionitis, third trimester, fetus 5 1/1/2021 12/31/2299 O411239 Chorioamnionitis, third trimester, other fetus 1/1/2021 12/31/2299 O411410 Placentitis, first trimester, not applicable or unspecified 1/1/2021 12/31/2299 O411411 Placentitis, first trimester, fetus 1 1/1/2021 12/31/2299 O411412 Placentitis, first trimester, fetus 2 1/1/2021 12/31/2299 O411413 Placentitis, first trimester, fetus 3 1/1/2021 12/31/2299 O411414 Placentitis, first trimester, fetus 4 1/1/2021 12/31/2299 O411415 Placentitis, first trimester, fetus 5 1/1/2021 12/31/2299 O411419 Placentitis, first trimester, other fetus 1/1/2021 12/31/2299 O411420 Placentitis, second trimester, not applicable or unspecified 1/1/2021 12/31/2299 O411421 Placentitis, second trimester, fetus 1 1/1/2021 12/31/2299 O411422 Placentitis, second trimester, fetus 2 1/1/2021 12/31/2299 O411423 Placentitis, second trimester, fetus 3 1/1/2021 12/31/2299 O411424 Placentitis, second trimester, fetus 4 1/1/2021 12/31/2299 O411425 Placentitis, second trimester, fetus 5 1/1/2021 12/31/2299 O411429 Placentitis, second trimester, other fetus 1/1/2021 12/31/2299 O411430 Placentitis, third trimester, not applicable or unspecified 1/1/2021 12/31/2299 O411431 Placentitis, third trimester, fetus 1 1/1/2021 12/31/2299 O411432 Placentitis, third trimester, fetus 2 1/1/2021 12/31/2299
192 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O411433 Placentitis, third trimester, fetus 3 1/1/2021 12/31/2299 O411434 Placentitis, third trimester, fetus 4 1/1/2021 12/31/2299 O411435 Placentitis, third trimester, fetus 5 1/1/2021 12/31/2299 O411439 Placentitis, third trimester, other fetus 1/1/2021 12/31/2299 O418X10 Oth disrd of amniotic fluid and membrns, first tri, unsp 1/1/2021 12/31/2299 O418X11 Oth disrd of amniotic fluid and membrns, first tri, fetus 1 1/1/2021 12/31/2299 O418X12 Oth disrd of amniotic fluid and membrns, first tri, fetus 2 1/1/2021 12/31/2299 O418X13 Oth disrd of amniotic fluid and membrns, first tri, fetus 3 1/1/2021 12/31/2299 O418X14 Oth disrd of amniotic fluid and membrns, first tri, fetus 4 1/1/2021 12/31/2299 O418X15 Oth disrd of amniotic fluid and membrns, first tri, fetus 5 1/1/2021 12/31/2299 O418X19 Oth disrd of amniotic fluid and membrns, first tri, oth 1/1/2021 12/31/2299 O418X20 Oth disrd of amniotic fluid and membrns, second tri, unsp 1/1/2021 12/31/2299 O418X21 Oth disrd of amniotic fluid and membrns, second tri, fetus 1 1/1/2021 12/31/2299 O418X22 Oth disrd of amniotic fluid and membrns, second tri, fetus 2 1/1/2021 12/31/2299 O418X23 Oth disrd of amniotic fluid and membrns, second tri, fetus 3 1/1/2021 12/31/2299 O418X24 Oth disrd of amniotic fluid and membrns, second tri, fetus 4 1/1/2021 12/31/2299 O418X25 Oth disrd of amniotic fluid and membrns, second tri, fetus 5 1/1/2021 12/31/2299 O418X29 Oth disrd of amniotic fluid and membrns, second tri, oth 1/1/2021 12/31/2299 O418X30 Oth disrd of amniotic fluid and membrns, third tri, unsp 1/1/2021 12/31/2299 O418X31 Oth disrd of amniotic fluid and membrns, third tri, fetus 1 1/1/2021 12/31/2299 O418X32 Oth disrd of amniotic fluid and membrns, third tri, fetus 2 1/1/2021 12/31/2299 O418X33 Oth disrd of amniotic fluid and membrns, third tri, fetus 3 1/1/2021 12/31/2299 O418X34 Oth disrd of amniotic fluid and membrns, third tri, fetus 4 1/1/2021 12/31/2299 O418X35 Oth disrd of amniotic fluid and membrns, third tri, fetus 5 1/1/2021 12/31/2299 O418X39 Oth disrd of amniotic fluid and membrns, third tri, oth 1/1/2021 12/31/2299 O4191X0 Disorder of amnio fluid and membrns, unsp, first tri, unsp 1/1/2021 12/31/2299 O4191X1 Disord of amnio fluid and membrns, unsp, first tri, fetus 1 1/1/2021 12/31/2299 O4191X2 Disord of amnio fluid and membrns, unsp, first tri, fetus 2 1/1/2021 12/31/2299 O4191X3 Disord of amnio fluid and membrns, unsp, first tri, fetus 3 1/1/2021 12/31/2299 O4191X4 Disord of amnio fluid and membrns, unsp, first tri, fetus 4 1/1/2021 12/31/2299 O4191X5 Disord of amnio fluid and membrns, unsp, first tri, fetus 5 1/1/2021 12/31/2299 O4191X9 Disorder of amniotic fluid and membrns, unsp, first tri, oth 1/1/2021 12/31/2299
193 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O4192X0 Disorder of amnio fluid and membrns, unsp, second tri, unsp 1/1/2021 12/31/2299 O4192X1 Disord of amnio fluid and membrns, unsp, second tri, fetus 1 1/1/2021 12/31/2299 O4192X2 Disord of amnio fluid and membrns, unsp, second tri, fetus 2 1/1/2021 12/31/2299 O4192X3 Disord of amnio fluid and membrns, unsp, second tri, fetus 3 1/1/2021 12/31/2299 O4192X4 Disord of amnio fluid and membrns, unsp, second tri, fetus 4 1/1/2021 12/31/2299 O4192X5 Disord of amnio fluid and membrns, unsp, second tri, fetus 5 1/1/2021 12/31/2299 O4192X9 Disorder of amnio fluid and membrns, unsp, second tri, oth 1/1/2021 12/31/2299 O4193X0 Disorder of amnio fluid and membrns, unsp, third tri, unsp 1/1/2021 12/31/2299 O4193X1 Disord of amnio fluid and membrns, unsp, third tri, fetus 1 1/1/2021 12/31/2299 O4193X2 Disord of amnio fluid and membrns, unsp, third tri, fetus 2 1/1/2021 12/31/2299 O4193X3 Disord of amnio fluid and membrns, unsp, third tri, fetus 3 1/1/2021 12/31/2299 O4193X4 Disord of amnio fluid and membrns, unsp, third tri, fetus 4 1/1/2021 12/31/2299 O4193X5 Disord of amnio fluid and membrns, unsp, third tri, fetus 5 1/1/2021 12/31/2299 O4193X9 Disorder of amniotic fluid and membrns, unsp, third tri, oth 1/1/2021 12/31/2299 O42011 Pretrm prem ROM, onset labor w/n 24 hours of rupt, first tri 1/1/2021 12/31/2299 O42012 Pretrm prem ROM, onset labor w/n 24 hours of rupt, 2nd tri 1/1/2021 12/31/2299 O42013 Pretrm prem ROM, onset labor w/n 24 hours of rupt, third tri 1/1/2021 12/31/2299 O42111 Pretrm prem ROM, onset labor > 24 hours fol rupt, first tri 1/1/2021 12/31/2299 O42112 Pretrm prem ROM, onset labor > 24 hours fol rupt, second tri 1/1/2021 12/31/2299 O42113 Pretrm prem ROM, onset labor > 24 hours fol rupt, third tri 1/1/2021 12/31/2299 O42911 Pretrm prem ROM, unsp time betw rupt and onset labr, 1st tri 1/1/2021 12/31/2299 O42912 Pretrm prem ROM, unsp time betw rupt and onset labr, 2nd tri 1/1/2021 12/31/2299 O42913 Pretrm prem ROM, unsp time betw rupt and onst labr, 3rd tri 1/1/2021 12/31/2299 O43011 Fetomaternal placental transfusion syndrome, first trimester 1/1/2021 12/31/2299 O43012 Fetomaternal placental transfuse syndrome, second trimester 1/1/2021 12/31/2299 O43013 Fetomaternal placental transfusion syndrome, third trimester 1/1/2021 12/31/2299 O43021 Fetus-to-fetus placental transfuse syndrome, first trimester 1/1/2021 12/31/2299 O43022 Fetus-to-fetus placntl transfuse syndrome, second trimester 1/1/2021 12/31/2299 O43023 Fetus-to-fetus placental transfuse syndrome, third trimester 1/1/2021 12/31/2299 O43101 Malformation of placenta, unspecified, first trimester 1/1/2021 12/31/2299 O43102 Malformation of placenta, unspecified, second trimester 1/1/2021 12/31/2299 O43103 Malformation of placenta, unspecified, third trimester 1/1/2021 12/31/2299
194 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
O43111 Circumvallate placenta, first trimester 1/1/2021 12/31/2299 O43112 Circumvallate placenta, second trimester 1/1/2021 12/31/2299 O43113 Circumvallate placenta, third trimester 1/1/2021 12/31/2299 O43191 Other malformation of placenta, first trimester 1/1/2021 12/31/2299 O43192 Other malformation of placenta, second trimester 1/1/2021 12/31/2299 O43193 Other malformation of placenta, third trimester 1/1/2021 12/31/2299 O43811 Placental infarction, first trimester 1/1/2021 12/31/2299 O43812 Placental infarction, second trimester 1/1/2021 12/31/2299 O43813 Placental infarction, third trimester 1/1/2021 12/31/2299 O43891 Other placental disorders, first trimester 1/1/2021 12/31/2299 O43892 Other placental disorders, second trimester 1/1/2021 12/31/2299 O43893 Other placental disorders, third trimester 1/1/2021 12/31/2299 O4391 Unspecified placental disorder, first trimester 1/1/2021 12/31/2299 O4392 Unspecified placental disorder, second trimester 1/1/2021 12/31/2299 O4393 Unspecified placental disorder, third trimester 1/1/2021 12/31/2299 O610 Failed medical induction of labor 1/1/2021 12/31/2299 O611 Failed instrumental induction of labor 1/1/2021 12/31/2299 O68 Labor and delivery comp by abnlt of fetal acid-base balance 1/1/2021 12/31/2299 O752 Pyrexia during labor, not elsewhere classified 1/1/2021 12/31/2299 O753 Other infection during labor 1/1/2021 12/31/2299 O755 Delayed delivery after artificial rupture of membranes 1/1/2021 12/31/2299 O7589 Other specified complications of labor and delivery 1/1/2021 12/31/2299 O759 Complication of labor and delivery, unspecified 1/1/2021 12/31/2299 O76 Abnlt in fetal heart rate and rhythm comp labor and delivery 1/1/2021 12/31/2299 Z331 Pregnant state, incidental 1/1/2021 12/31/2299 Z31430 Encntr fem for test for genetc dis carrier stat for pro mgmt 1/1/2021 12/31/2299 Z31440 Encntr male test for genetic dis carrier status for pro mgmt 1/1/2021 12/31/2299 Z3400 Encntr for suprvsn of normal first pregnancy, unsp trimester 1/1/2021 12/31/2299 Z3401 Encntr for suprvsn of normal first preg, first trimester 1/1/2021 12/31/2299 Z3402 Encntr for suprvsn of normal first preg, second trimester 1/1/2021 12/31/2299 Z3403 Encntr for suprvsn of normal first preg, third trimester 1/1/2021 12/31/2299 Z3480 Encounter for suprvsn of normal pregnancy, unsp trimester 1/1/2021 12/31/2299
195 Table 11a ICD-10-CM Diagnosis Codes Bypass PA for SMA Lab Procedure 81329 ICD-10-CM ICD-10-CM descriptions Effective End Date codes Date
Z3481 Encounter for suprvsn of normal pregnancy, first trimester 1/1/2021 12/31/2299 Z3482 Encounter for suprvsn of normal pregnancy, second trimester 1/1/2021 12/31/2299 Z3483 Encounter for suprvsn of normal pregnancy, third trimester 1/1/2021 12/31/2299 Z3490 Encntr for suprvsn of normal pregnancy, unsp, unsp trimester 1/1/2021 12/31/2299 Z3491 Encntr for suprvsn of normal preg, unsp, first trimester 1/1/2021 12/31/2299 Z3492 Encntr for suprvsn of normal preg, unsp, second trimester 1/1/2021 12/31/2299 Z3493 Encntr for suprvsn of normal preg, unsp, third trimester 1/1/2021 12/31/2299
Table Listing, Previous Table 11a, Next Table 13a, End of Document
Table 12: ICD-10 CM TB Diagnosis Codes for Tuberculosis Eligibility Waiver
Table ICD-10-CM TB Diagnosis Codes for Tuberculosis Eligibility Waiver 12 ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes A150 Tuberculosis of lung 10/1/2015 12/31/2299 A154 Tuberculosis of intrathoracic lymph nodes 10/1/2015 12/31/2299 A155 Tuberculosis of larynx, trachea and bronchus 10/1/2015 12/31/2299 A156 Tuberculous pleurisy 10/1/2015 12/31/2299 A157 Primary respiratory tuberculosis 10/1/2015 12/31/2299 A158 Other respiratory tuberculosis 10/1/2015 12/31/2299 A159 Respiratory tuberculosis unspecified 10/1/2015 12/31/2299 A170 Tuberculous meningitis 10/1/2015 12/31/2299 A171 Meningeal tuberculoma 10/1/2015 12/31/2299 A1781 Tuberculoma of brain and spinal cord 10/1/2015 12/31/2299 A1782 Tuberculous meningoencephalitis 10/1/2015 12/31/2299 A1783 Tuberculous neuritis 10/1/2015 12/31/2299 A1789 Other tuberculosis of nervous system 10/1/2015 12/31/2299 A179 Tuberculosis of nervous system, unspecified 10/1/2015 12/31/2299 A1801 Tuberculosis of spine 10/1/2015 12/31/2299
196 Table ICD-10-CM TB Diagnosis Codes for Tuberculosis Eligibility Waiver 12 ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes A1802 Tuberculous arthritis of other joints 10/1/2015 12/31/2299 A1803 Tuberculosis of other bones 10/1/2015 12/31/2299 A1809 Other musculoskeletal tuberculosis 10/1/2015 12/31/2299 A1810 Tuberculosis of genitourinary system, unspecified 10/1/2015 12/31/2299 A1811 Tuberculosis of kidney and ureter 10/1/2015 12/31/2299 A1812 Tuberculosis of bladder 10/1/2015 12/31/2299 A1813 Tuberculosis of other urinary organs 10/1/2015 12/31/2299 A1814 Tuberculosis of prostate 10/1/2015 12/31/2299 A1815 Tuberculosis of other male genital organs 10/1/2015 12/31/2299 A1816 Tuberculosis of cervix 10/1/2015 12/31/2299 A1817 Tuberculous female pelvic inflammatory disease 10/1/2015 12/31/2299 A1818 Tuberculosis of other female genital organs 10/1/2015 12/31/2299 A182 Tuberculous peripheral lymphadenopathy 10/1/2015 12/31/2299 A1831 Tuberculous peritonitis 10/1/2015 12/31/2299 A1832 Tuberculous enteritis 10/1/2015 12/31/2299 A1839 Retroperitoneal tuberculosis 10/1/2015 12/31/2299 A184 Tuberculosis of skin and subcutaneous tissue 10/1/2015 12/31/2299 A1850 Tuberculosis of eye, unspecified 10/1/2015 12/31/2299 A1851 Tuberculous episcleritis 10/1/2015 12/31/2299 A1852 Tuberculous keratitis 10/1/2015 12/31/2299 A1853 Tuberculous chorioretinitis 10/1/2015 12/31/2299 A1854 Tuberculous iridocyclitis 10/1/2015 12/31/2299 A1859 Other tuberculosis of eye 10/1/2015 12/31/2299 A186 Tuberculosis of (inner) (middle) ear 10/1/2015 12/31/2299 A187 Tuberculosis of adrenal glands 10/1/2015 12/31/2299 A1881 Tuberculosis of thyroid gland 10/1/2015 12/31/2299 A1882 Tuberculosis of other endocrine glands 10/1/2015 12/31/2299 A1883 Tuberculosis of digestive tract organs, NEC 10/1/2015 12/31/2299 A1884 Tuberculosis of heart 10/1/2015 12/31/2299 A1885 Tuberculosis of spleen 10/1/2015 12/31/2299 A1889 Tuberculosis of other sites 10/1/2015 12/31/2299
197 Table ICD-10-CM TB Diagnosis Codes for Tuberculosis Eligibility Waiver 12 ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes A190 Acute miliary tuberculosis of a single specified site 10/1/2015 12/31/2299 A191 Acute miliary tuberculosis of multiple sites 10/1/2015 12/31/2299 A192 Acute miliary tuberculosis, unspecified 10/1/2015 12/31/2299 A198 Other miliary tuberculosis 10/1/2015 12/31/2299 A199 Miliary tuberculosis, unspecified 10/1/2015 12/31/2299 B900 Sequelae of central nervous system tuberculosis 10/1/2015 12/31/2299 B901 Sequelae of genitourinary tuberculosis 10/1/2015 12/31/2299 B902 Sequelae of tuberculosis of bones and joints 10/1/2015 12/31/2299 B908 Sequelae of tuberculosis of other organs 10/1/2015 12/31/2299 B909 Sequelae of respiratory and unspecified tuberculosis 10/1/2015 12/31/2299 O98011 Tuberculosis complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98012 Tuberculosis complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98013 Tuberculosis complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98019 Tuberculosis complicating pregnancy, unspecified trimester 10/1/2015 12/31/2299 O9802 Tuberculosis complicating childbirth 10/1/2015 12/31/2299 O9803 Tuberculosis complicating the puerperium 10/1/2015 12/31/2299 P370 Congenital tuberculosis 10/1/2015 12/31/2299 R7611 Nonspecific reaction to skin test w/o active tuberculosis 10/1/2015 12/31/2299 R7612 Nonspec reaction to gamma intrfrn respns w/o actv tubrclosis 10/1/2015 12/31/2299
198 Table Listing, Previous Table 12, Next Table 13b, End of Document
Table 13: High Risk Obstetrical Radiology Services
Table 13a: ICD-9-CM Diagnosis Codes for High Risk Obstetrical Radiology Services
Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 632 Missed Abortion 63300 Abd Pregnancy Without Intrauterine Pregnancy 63301 Abdominal Pregnancy With Intrauterine Pregnancy 63310 Tubal Pregnancy Without Intrauterine Pregnancy 63311 Tubal Pregnancy With Intrauterine Pregnancy 63320 Ovarian Pregnancy Without Intrauterine Pregnancy 63321 Ovarian Pregnancy With Intrauterine Pregnancy 63380 Other ectopic pregnancy without intrauterine pregnancy 63381 Other ectopic pregnancy without intrauterine pregnancy 63390 Unspecified ectopic pregnancy without intrauterine pregnancy 63391 Unspecified ectopic pregnancy with intrauterine pregnancy 63401 Incpl Spontaneous Ab Comp Genital Tract&Pelv Inf 63402 Complete Spont Ab Comp Genital Tract&Pelv Inf 63411 Incpl Spontaneous Ab Comp Delay/Excess Hemorr 63412 Complete Spontaneous Ab Comp Delay/Excess Hemorr 63421 Incpl Spont Ab Comp Damge Pelv Orgn/Tissues 63422 Complete Spont Ab Comp Damge Pelv Orgn/Tissues 63431 Incomplete Spontaneous Ab Comp Renal Failure 63432 Complete Spontaneous Ab Comp Renal Failure 63441 Incpl Spontaneous Ab Comp Metabolic Disorder 63442 Complete Spontaneous Ab Comp Metabolic Disorder 63451 Incomplete Spontaneous Ab Complicated Shock 63452 Complete Spontaneous Abortion Complicated Shock
199 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 63461 Incomplete Spontaneous Ab Complicated Embolism 63462 Complete Spontaneous Ab Complicated Embolism 64003 Threatened Abortion, Antepartum 64103 Placenta Previa Without Hemorrhage Antepartum 64113 Hemorrhage From Placenta Previa Antepartum 64123 Premature Separation Of Placenta Antepartum 64133 Antprtm Hemorr Assoc W/Coagulat Defect Antprtm 64193 Unspecified antepartum hemorrhage, antepartum condition or complication 64213 Hypertension Sec To Renal Disease Antepartum 64223 Other Pre-Existing Hypertension Antepartum 64233 Transient Hypertension Of Pregnancy Antepartum 64243 Mild Or Unspecified Pre-Eclampsia Antepartum 64253 Severe Pre-Eclampsia, Antepartum 64263 Eclampsia, Antepartum 64273 Pre-Eclampsia/Eclampsia Pre-Exist Htn Antepartum 64313 Hyperemesis Gravida W/Metab Disturbance Antprtm 64323 Late Vomiting Of Pregnancy Antepartum 64403 Threatened Premature Labor Antepartum 64413 Other Threatened Labor, Antepartum 64513 Post Term Pregnancy Antepartum Cond/Complication 64523 Prolonged Pregnancy Delivered Antprtm Cond/Comp 64613 Edema Or Excessive Weight Gain Antepartum 64633 Recurrent Pregnancy Loss, Antepartum Condition Or Complication 64643 Peripheral Neuritis Antepartum 64653 Asymptomatic Bacteriuria Antepartum 64663 Infections Of Genitourinary Tract Antepartum 64673 Liver And Biliary Tract Disorders In Pregnancy, Antepartum Condition Or Complication 64703 Maternal Syphilis, Antepartum 64713 Maternal Gonorrhea, Antepartum 64723 Oth Antprtm Mtrn Vnerel Disease Previous Pp Cond
200 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 64733 Maternal Tuberculosis, Antepartum 64743 Maternal Malaria, Antepartum 64753 Maternal Rubella, Antepartum 64763 Other Maternal Viral Disease Antepartum 64803 Maternal Diabetes Mellitus Antepartum 64813 Maternal Thyroid Dysfunction Antprtm Cond/Comp 64823 Maternal Anemia, Antepartum 64833 Maternal Drug Dependence Antepartum 64843 Maternal Mental Disorders Antepartum 64853 Maternal Congenital Cv Disorders Antprtm 64863 Oth Maternal Cardiovascular Diseases Antepartum 64873 Bn&Jnt D/O Mat Back Pelvis&Lw Limbs Antepartum 64883 Abnormal Maternal Glucose Tolerance Antepartum 64903 Tob Use D/O Comp Pg Birth/Pp Antepartm Cond/Comp 64913 Obes Comp Pg Birth/The Pp Antepartum Cond/Comp 64923 Bariatric Surg Sts Comp Pg Birth/Pp Ap Cond/Comp 64933 Coagulat Defec Comp Pg Birth/The Pp Ap Cond/Comp 64943 Epilepsy Comp Pg Birth/Pp Antepartum Cond/Comp 64953 Spotting Comp Pregnancy Antepartum Cond/Comp 64963 Uterine Size Date Discrepancy Antprtm Cond/Compl 64973 Cervical Shortening Antepartum Condition Or Comp 65103 Twin Pregnancy, Antepartum 65113 Triplet Pregnancy, Antepartum 65123 Quadruplet Pregnancy, Antepartum 65133 Twin Pg W/Fetal Loss&Retention 1 Fetus Antprtm 65143 Triplet Pg W/Fetal Loss&Retention 1/More Antprtm 65153 Quadruplet Pg W/Fetal Loss&Retn 1/More Antprtm 65163 Oth Mx Pg W/Fetal Loss&Retn 1/More Fetus Antprtm 65173 Mx Gest Flw Elctv Fetal Rduc Antprtm Cond/Compl 65203 Unstable Lie Of Fetus, Antepartum
201 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 65213 Breech/Malpresent Converted To Cephalic-Apc/C 65223 Breech Presentation W/O Mention Version Antprtm 65233 Transverse/Oblique Fetal Presentation Antepartum 65243 Fetal Face Or Brow Presentation Antepartum 65253 High Fetal Head At Term, Antepartum 65263 Mx Gest W/Malpresentation 1 Fetus/More Antprtm 65273 Prolapsed Arm Fetus Antepartum Cond/Complication 65303 Major Abnorm Bony Pelv Not Further Spec Antprtm 65313 Generally Contracted Pelvis Pregnancy Antepartum 65323 Inlet Contraction Of Pelvis Pregnancy Antepartum 65333 Outlet Contraction Pelvis Pregnancy Antepartum 65343 Fetopelvic Disproportion Antepartum 65353 Unusually Large Fetus Causing Disproprtn Antprtm 65363 Hydrocephalic Fetus Causing Disproprtn Antprtm 65373 Oth Fetal Abnorm Causing Disproprtn Antepartum 65383 Fetal Disproportion Of Other Origin Antepartum 65403 Congenital Abnorm Pregnant Uterus Antepartum 65413 Tumors Body Uterus Antepartum Cond/Complication 65423 Previous C-Sect Delivery Antprtm Cond/Comp 65433 Retroverted&Incarcerated Gravid Uterus Antprtm 65443 Oth Abn Shape/Position Gravid Uterus Antepartum 65453 Cervical Incompetence Antprtm Cond/Complication 65463 Oth Congenital/Acq Abnorm Cerv Antprtm Cond/Comp 65473 Congenital/Acq Abnorm Vagina Antprtm Cond/Comp 65483 Congenital/Acq Abnorm Vulva Antprtm Cond/Comp 65503 Cntrl Nerv Sys Malformation In Fetus Antepartum 65513 Chromosom Abnorm Fetus Affect Mgmt Mom Antprtm 65533 Spct Damge Fetus Viral Dz Mom Antprtm Compl 65543 Spct Damge Fetus Oth Dz Mom Antprtm Cond/Compl 65553 Spct Damge Fetus From Rx Affct Mgmt Moth Antprtm
202 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 65563 Spct Damge Fetus Rad Mgmt Moth Antprtm Cond/Comp 65573 Decr Fetal Movmnts Mgmt Moth Antprtm Cond/Comp 65583 Oth Known/Suspected Fetal Abnormality-Nec-Apc/C 65603 Fetal-Maternal Hemorrhage Antprtm Cond/Comp 65613 Rhesus Isoimmun Affct Mgmt Moth Antprtm Cond 65623 Isoimmu Uns Bld-Grp Incompat Mgmt Moth Antprtm 65633 Fetal Distress Affect Management Moth Antepartum 65643 Intrauterine Death Affect Mgmt Moth Antprtm 65653 Poor Fetal Growth Mgmt Moth Antprtm Cond/Comp 65663 Excess Fetal Growth Affect Mgmt Moth Antprtm 65673 Oth Placental Conds Affect Mgmt Moth Antprtm 65683 Oth Spec Fetal&Placntl Probs Mgmt Moth Antprtm 65703 Polyhydramnios Antepartum Complication 65803 Oligohydramnios, Antepartum 65813 Premature Rupture Membranes Pregnancy Antepartum 65823 Delay Deliv After Spont/Unspec Rup Memb Antprtm 65833 Delay Deliv After Artficl Rupture Memb Antprtm 65843 Infection Of Amniotic Cavity Antepartum 65883 Oth Problem Assoc W/Amniotic Cavity&Memb Antprtm 65903 Failed Mechanical Induction Of Labor Antepartum 65913 Failed Medical/Unspec Induction Labor Antepartum 65923 Unspecified Maternal Pyrexia Antepartum 65933 Generalized Infection During Labor Antepartum 65943 Grand Multiparity W/Current Pregnancy Antepartum 65953 Elderly Primigravida, Antepartum 65963 Elderly Multigravida W/Antprtm Cond/Complication 65973 Abnorm Fetal Heart Rate/Rhythm Antprtm Cond/Comp 65983 Oth Spec Indicat Care/Interven Rel L&D Antprtm 66003 Obst Caus Malposition Fetus@Onset Labr Antprtm 66013 Obstruction By Bony Pelvis During L&D Antepartum
203 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 66023 Obst Abnorm Pelv Soft Tiss Dur L&D Antprtm 66033 Deep Transverse Arrest-Occipitopost Posit-Apc/C 66043 Shoulder Dystocia During L&D Antepartum 66053 Locked Twins, Antepartum 66063 Unspecified Failed Trial Of Labor Antepartum 66073 Failed Forceps/Vac Ext Unspec Antepartum 66083 Other Causes Of Obstructed Labor Antepartum 66103 Primary Uterine Inertia, Antepartum 66113 Secondary Uterine Inertia Antepartum 66123 Other And Unspecified Uterine Inertia Antepartum 66133 Precipitate Labor, Antepartum 66143 Hyperton Incoord/Prolng Uterine Contracs Antprtm 66203 Prolonged First Stage Of Labor Antepartum 66223 Prolonged Second Stage Of Labor Antepartum 66233 Delayed Delivery 2 Twin Triplet Etc Antepartum 66303 Prolapse Of Cord Complicating L&D Antepartum 66313 Cord Around Neck W/Compression Comp L&D Antprtm 66323 Oth&Uns Cord Entangl W/Comprs Comp L&D Antprtm 66343 Short Cord Complicating L&D Antepartum 66353 Vasa Previa Complicating L&D Antepartum 66363 Vascular Lesions Cord Complicating L&D Antprtm 66383 Oth Umbilical Cord Comps During L&D Antprtm 67133 Deep Phlebothrombosis Antprtm-Antprtm Cond/Comp 67153 Other Antepartum Phlebitis And Thrombosis 67303 Obstetrical Air Embolism Antprtm Cond/Comp 67313 Amniotic Fluid Embolism Antprtm Cond/Comp 67323 Obstetrical Blood-Clot Embolism Antepartum 67333 Obstetrical Pyemic&Septic Embolism Antepartum 67403 Cerebrovascular Disorder Antepartum V230 Pregnancy With History Of Infertility
204 Table 13a Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD-9- Policy requirement effective 7/1/2015. CM codes ICD-9-CM descriptions effective through 9/30/2015 effective 7/01/2015 through 9/30/2015 V231 Pregnancy With History Of Trophoblastic Disease V232 Pregnancy With History Of Abortion V233 Pregnancy With Grand Multiparity V2341 Supervision Pregnancy W/History Pre-Term Labor V2342 Pregnancy With History Of Ectopic Pregnancy V2349 Supervision Pregnancy W/Oth Poor Obstetric Hx V235 Pregnancy With Other Poor Reproductive History V237 Insufficient Prenatal Care V2381 Supervision High-Risk Pg Elder Primigravida V2382 Supervision High-Risk Pg Elder Multigravida V2383 Supervision High-Risk Pg Young Primigravida V2384 Supervision High-Risk Pg Young Multigravida V2385 Pregnt-Assist Repro Tech V2386 Preg-Hx In Utro Prev Prg V2387 Pregnancy With Inconclusive Fetal Viability V284 Antenatal screening for fetal growth retardation using ultrasonics V2882 Encounter for screening for risk of pre-term labor V2889 Other specified antenatal screening V289 Unspecified antenatal screening V8901 Suspected problem with amniotic cavity and membrane not found V8902 Suspected placental problem not found V8903 Suspected fetal anomaly not found V8905 Suspected cervical shortening not found V8909 Other suspected maternal and fetal condition not found
205 Table Listing, Previous Table 13a, Next Table 14, End of Document
Table 13b: ICD-10-CM Diagnosis Codes for High Risk Obstetrical Radiology Services
Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O000 Abdominal pregnancy 10/1/2015 9/30/2016 O0000 Abdominal pregnancy without intrauterine pregnancy 10/1/2016 12/31/2299 O0001 Abdominal pregnancy with intrauterine pregnancy 10/1/2016 12/31/2299 O001 Tubal pregnancy 10/1/2015 9/30/2016 O0010 Tubal pregnancy without intrauterine pregnancy 10/1/2016 9/30/2017 O00101 Right tubal pregnancy without intrauterine pregnancy 10/1/2017 12/31/2299 O00102 Left tubal pregnancy without intrauterine pregnancy 10/1/2017 12/31/2299 O0011 Tubal pregnancy with intrauterine pregnancy 10/1/2016 9/30/2017 O00111 Right tubal pregnancy with intrauterine pregnancy 10/1/2017 12/31/2299 O00112 Left tubal pregnancy with intrauterine pregnancy 10/1/2017 12/31/2299 O002 Ovarian pregnancy 10/1/2015 9/30/2016 O0020 Ovarian pregnancy without intrauterine pregnancy 10/1/2016 9/30/2017 O00201 Right ovarian pregnancy without intrauterine pregnancy 10/1/2017 12/31/2299 O00202 Left ovarian pregnancy without intrauterine pregnancy 10/1/2017 12/31/2299 O0021 Ovarian pregnancy with intrauterine pregnancy 10/1/2016 9/30/2017 O00211 Right ovarian pregnancy with intrauterine pregnancy 10/1/2017 12/31/2299 O00212 Left ovarian pregnancy without intrauterine pregnancy 10/1/2017 12/31/2299 O021 Missed abortion 10/1/2015 12/31/2299 O030 Genitl trct and pelvic infection fol incmpl spon abortion 10/1/2015 12/31/2299 O031 Delayed or excessive hemor following incmpl spon abortion 10/1/2015 12/31/2299 O032 Embolism following incomplete spontaneous abortion 10/1/2015 12/31/2299 O0331 Shock following incomplete spontaneous abortion 10/1/2015 12/31/2299 O0332 Renal failure following incomplete spontaneous abortion 10/1/2015 12/31/2299 O0333 Metabolic disorder following incomplete spontaneous abortion 10/1/2015 12/31/2299 O0334 Damage to pelvic organs following incomplete spon abortion 10/1/2015 12/31/2299 O0337 Sepsis following incomplete spontaneous abortion 10/1/2015 12/31/2299 O035 Genitl trct and pelvic infct fol complete or unsp spon abort 10/1/2015 12/31/2299 O036 Delayed or excess hemor fol complete or unsp spon abortion 10/1/2015 12/31/2299
206 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O037 Embolism following complete or unsp spontaneous abortion 10/1/2015 12/31/2299 O0381 Shock following complete or unspecified spontaneous abortion 10/1/2015 12/31/2299 O0382 Renal failure following complete or unsp spon abortion 10/1/2015 12/31/2299 O0383 Metabolic disorder following complete or unsp spon abortion 10/1/2015 12/31/2299 O0384 Damage to pelvic organs fol complete or unsp spon abortion 10/1/2015 12/31/2299 O0387 Sepsis following complete or unsp spontaneous abortion 10/1/2015 12/31/2299 O0901 Suprvsn of preg w history of infertility, first trimester 10/1/2015 12/31/2299 O0902 Suprvsn of preg w history of infertility, second trimester 10/1/2015 12/31/2299 O0903 Suprvsn of preg w history of infertility, third trimester 10/1/2015 12/31/2299 O0911 Suprvsn of preg with history of ectopic preg, first tri 10/1/2015 12/31/2299 O0912 Suprvsn of preg with history of ectopic preg, second tri 10/1/2015 12/31/2299 O0913 Suprvsn of preg with history of ectopic preg, third tri 10/1/2015 12/31/2299 O09211 Suprvsn of preg w history of pre-term labor, first trimester 10/1/2015 12/31/2299 O09212 Suprvsn of preg w history of pre-term labor, second tri 10/1/2015 12/31/2299 O09213 Suprvsn of preg w history of pre-term labor, third trimester 10/1/2015 12/31/2299 O09291 Suprvsn of preg w poor reprodctv or obstet hx, first tri 10/1/2015 12/31/2299 O09292 Suprvsn of preg w poor reprodctv or obstet hx, second tri 10/1/2015 12/31/2299 O09293 Suprvsn of preg w poor reprodctv or obstet hx, third tri 10/1/2015 12/31/2299 O0931 Suprvsn of preg w insufficient antenat care, first trimester 10/1/2015 12/31/2299 O0932 Suprvsn of preg w insufficient antenat care, second tri 10/1/2015 12/31/2299 O0933 Suprvsn of preg w insufficient antenat care, third trimester 10/1/2015 12/31/2299 O0941 Suprvsn of pregnancy w grand multiparity, first trimester 10/1/2015 12/31/2299 O0942 Suprvsn of pregnancy w grand multiparity, second trimester 10/1/2015 12/31/2299 O0943 Suprvsn of pregnancy w grand multiparity, third trimester 10/1/2015 12/31/2299 O09511 Supervision of elderly primigravida, first trimester 10/1/2015 12/31/2299 O09512 Supervision of elderly primigravida, second trimester 10/1/2015 12/31/2299 O09513 Supervision of elderly primigravida, third trimester 10/1/2015 12/31/2299 O09521 Supervision of elderly multigravida, first trimester 10/1/2015 12/31/2299 O09522 Supervision of elderly multigravida, second trimester 10/1/2015 12/31/2299 O09523 Supervision of elderly multigravida, third trimester 10/1/2015 12/31/2299 O09611 Supervision of young primigravida, first trimester 10/1/2015 12/31/2299 O09612 Supervision of young primigravida, second trimester 10/1/2015 12/31/2299
207 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O09613 Supervision of young primigravida, third trimester 10/1/2015 12/31/2299 O09621 Supervision of young multigravida, first trimester 10/1/2015 12/31/2299 O09622 Supervision of young multigravida, second trimester 10/1/2015 12/31/2299 O09623 Supervision of young multigravida, third trimester 10/1/2015 12/31/2299 O09812 Suprvsn of preg rslt from assist reprodctv tech, second tri 10/1/2015 12/31/2299 O09813 Suprvsn of preg rslt from assisted reprodctv tech, third tri 10/1/2015 12/31/2299 O09819 Suprvsn of preg rslt from assisted reprodctv tech, unsp tri 10/1/2015 12/31/2299 O09821 Suprvsn of preg w hx of in utero proc dur prev preg, 1st tri 10/1/2015 12/31/2299 O09822 Suprvsn of preg w hx of in utero proc dur prev preg, 2nd tri 10/1/2015 12/31/2299 O09823 Suprvsn of preg w hx of in utero proc dur prev preg, 3rd tri 10/1/2015 12/31/2299 O09A1 Suprvsn of preg with history of molar preg, first trimester 10/1/2016 12/31/2299 O09A2 Suprvsn of preg with history of molar preg, second trimester 10/1/2016 12/31/2299 O09A3 Suprvsn of preg with history of molar preg, third trimester 10/1/2016 12/31/2299 O10111 Pre-exist hyp heart disease comp pregnancy, first trimester 10/1/2015 12/31/2299 O10112 Pre-exist hyp heart disease comp pregnancy, second trimester 10/1/2015 12/31/2299 O10113 Pre-exist hyp heart disease comp pregnancy, third trimester 10/1/2015 12/31/2299 O10211 Pre-exist hyp chronic kidney disease comp preg, first tri 10/1/2015 12/31/2299 O10212 Pre-exist hyp chronic kidney disease comp preg, second tri 10/1/2015 12/31/2299 O10213 Pre-exist hyp chronic kidney disease comp preg, third tri 10/1/2015 12/31/2299 O10311 Pre-exist hyp heart and chr kidney dis comp preg, first tri 10/1/2015 12/31/2299 O10312 Pre-exist hyp heart and chr kidney dis comp preg, second tri 10/1/2015 12/31/2299 O10313 Pre-exist hyp heart and chr kidney dis comp preg, third tri 10/1/2015 12/31/2299 O10411 Pre-existing secondary htn comp pregnancy, first trimester 10/1/2015 12/31/2299 O10412 Pre-existing secondary htn comp pregnancy, second trimester 10/1/2015 12/31/2299 O10413 Pre-existing secondary htn comp pregnancy, third trimester 10/1/2015 12/31/2299 O111 Pre-existing hypertension w pre-eclampsia, first trimester 10/1/2015 12/31/2299 O112 Pre-existing hypertension w pre-eclampsia, second trimester 10/1/2015 12/31/2299 O113 Pre-existing hypertension w pre-eclampsia, third trimester 10/1/2015 12/31/2299 O1201 Gestational edema, first trimester 10/1/2015 12/31/2299 O1202 Gestational edema, second trimester 10/1/2015 12/31/2299 O1203 Gestational edema, third trimester 10/1/2015 12/31/2299 O1221 Gestational edema with proteinuria, first trimester 10/1/2015 12/31/2299
208 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O1222 Gestational edema with proteinuria, second trimester 10/1/2015 12/31/2299 O1223 Gestational edema with proteinuria, third trimester 10/1/2015 12/31/2299 O131 Gestational htn w/o significant proteinuria, first trimester 10/1/2015 12/31/2299 O132 Gestatnl htn w/o significant proteinuria, second trimester 10/1/2015 12/31/2299 O133 Gestational htn w/o significant proteinuria, third trimester 10/1/2015 12/31/2299 O1402 Mild to moderate pre-eclampsia, second trimester 10/1/2015 12/31/2299 O1403 Mild to moderate pre-eclampsia, third trimester 10/1/2015 12/31/2299 O1412 Severe pre-eclampsia, second trimester 10/1/2015 12/31/2299 O1413 Severe pre-eclampsia, third trimester 10/1/2015 12/31/2299 O1422 HELLP syndrome (HELLP), second trimester 10/1/2015 12/31/2299 O1423 HELLP syndrome (HELLP), third trimester 10/1/2015 12/31/2299 O1502 Eclampsia complicating pregnancy, second trimester 10/1/2015 12/31/2299 O1503 Eclampsia complicating pregnancy, third trimester 10/1/2015 12/31/2299 O200 Threatened abortion 10/1/2015 12/31/2299 O211 Hyperemesis gravidarum with metabolic disturbance 10/1/2015 12/31/2299 O212 Late vomiting of pregnancy 10/1/2015 12/31/2299 O2231 Deep phlebothrombosis in pregnancy, first trimester 10/1/2015 12/31/2299 O2232 Deep phlebothrombosis in pregnancy, second trimester 10/1/2015 12/31/2299 O2233 Deep phlebothrombosis in pregnancy, third trimester 10/1/2015 12/31/2299 O2251 Cerebral venous thrombosis in pregnancy, first trimester 10/1/2015 12/31/2299 O2252 Cerebral venous thrombosis in pregnancy, second trimester 10/1/2015 12/31/2299 O2253 Cerebral venous thrombosis in pregnancy, third trimester 10/1/2015 12/31/2299 O2291 Venous complication in pregnancy, unsp, first trimester 10/1/2015 12/31/2299 O2292 Venous complication in pregnancy, unsp, second trimester 10/1/2015 12/31/2299 O2293 Venous complication in pregnancy, unsp, third trimester 10/1/2015 12/31/2299 O2301 Infections of kidney in pregnancy, first trimester 10/1/2015 12/31/2299 O2302 Infections of kidney in pregnancy, second trimester 10/1/2015 12/31/2299 O2303 Infections of kidney in pregnancy, third trimester 10/1/2015 12/31/2299 O2311 Infections of bladder in pregnancy, first trimester 10/1/2015 12/31/2299 O2312 Infections of bladder in pregnancy, second trimester 10/1/2015 12/31/2299 O2313 Infections of bladder in pregnancy, third trimester 10/1/2015 12/31/2299 O2321 Infections of urethra in pregnancy, first trimester 10/1/2015 12/31/2299
209 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O2322 Infections of urethra in pregnancy, second trimester 10/1/2015 12/31/2299 O2323 Infections of urethra in pregnancy, third trimester 10/1/2015 12/31/2299 O2331 Infect of prt urinary tract in pregnancy, first trimester 10/1/2015 12/31/2299 O2332 Infect of prt urinary tract in pregnancy, second trimester 10/1/2015 12/31/2299 O2333 Infect of prt urinary tract in pregnancy, third trimester 10/1/2015 12/31/2299 O2341 Unsp infct of urinary tract in pregnancy, first trimester 10/1/2015 12/31/2299 O2342 Unsp infct of urinary tract in pregnancy, second trimester 10/1/2015 12/31/2299 O2343 Unsp infct of urinary tract in pregnancy, third trimester 10/1/2015 12/31/2299 O23511 Infections of cervix in pregnancy, first trimester 10/1/2015 12/31/2299 O23512 Infections of cervix in pregnancy, second trimester 10/1/2015 12/31/2299 O23513 Infections of cervix in pregnancy, third trimester 10/1/2015 12/31/2299 O23521 Salpingo-oophoritis in pregnancy, first trimester 10/1/2015 12/31/2299 O23522 Salpingo-oophoritis in pregnancy, second trimester 10/1/2015 12/31/2299 O23523 Salpingo-oophoritis in pregnancy, third trimester 10/1/2015 12/31/2299 O23591 Infection oth prt genitl trct in pregnancy, first trimester 10/1/2015 12/31/2299 O23592 Infection oth prt genitl trct in pregnancy, second trimester 10/1/2015 12/31/2299 O23593 Infection oth prt genitl trct in pregnancy, third trimester 10/1/2015 12/31/2299 O24011 Pre-existing type 1 diabetes, in pregnancy, first trimester 10/1/2015 12/31/2299 O24012 Pre-existing type 1 diabetes, in pregnancy, second trimester 10/1/2015 12/31/2299 O24013 Pre-existing type 1 diabetes, in pregnancy, third trimester 10/1/2015 12/31/2299 O24111 Pre-existing type 2 diabetes, in pregnancy, first trimester 10/1/2015 12/31/2299 O24112 Pre-existing type 2 diabetes, in pregnancy, second trimester 10/1/2015 12/31/2299 O24113 Pre-existing type 2 diabetes, in pregnancy, third trimester 10/1/2015 12/31/2299 O24410 Gestational diabetes mellitus in pregnancy, diet controlled 10/1/2015 12/31/2299 O24414 Gestational diabetes in pregnancy, insulin controlled 10/1/2015 12/31/2299 O24415 Gestatnl diabetes in preg, ctrl by oral hypoglycemic drugs 10/1/2016 12/31/2299 O24419 Gestational diabetes mellitus in pregnancy, unsp control 10/1/2015 12/31/2299 O24425 Gestatnl diab in chldbrth, ctrl by oral hypoglycemic drugs 10/1/2016 12/31/2299 O24435 Gestatnl diabetes in puerp, ctrl by oral hypoglycemic drugs 10/1/2016 12/31/2299 O2601 Excessive weight gain in pregnancy, first trimester 10/1/2015 12/31/2299 O2602 Excessive weight gain in pregnancy, second trimester 10/1/2015 12/31/2299 O2603 Excessive weight gain in pregnancy, third trimester 10/1/2015 12/31/2299
210 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O2621 Preg care for patient w recurrent preg loss, first trimester 10/1/2015 12/31/2299 O2622 Preg care for patient w recur preg loss, second trimester 10/1/2015 12/31/2299 O2623 Preg care for patient w recurrent preg loss, third trimester 10/1/2015 12/31/2299 O26611 Liver and biliary tract disord in pregnancy, first trimester 10/1/2015 12/31/2299 O26612 Liver and biliary tract disord in preg, second trimester 10/1/2015 12/31/2299 O26613 Liver and biliary tract disord in pregnancy, third trimester 10/1/2015 12/31/2299 O26821 Pregnancy related peripheral neuritis, first trimester 10/1/2015 12/31/2299 O26822 Pregnancy related peripheral neuritis, second trimester 10/1/2015 12/31/2299 O26823 Pregnancy related peripheral neuritis, third trimester 10/1/2015 12/31/2299 O26841 Uterine size-date discrepancy, first trimester 10/1/2015 12/31/2299 O26842 Uterine size-date discrepancy, second trimester 10/1/2015 12/31/2299 O26843 Uterine size-date discrepancy, third trimester 10/1/2015 12/31/2299 O26851 Spotting complicating pregnancy, first trimester 10/1/2015 12/31/2299 O26852 Spotting complicating pregnancy, second trimester 10/1/2015 12/31/2299 O26853 Spotting complicating pregnancy, third trimester 10/1/2015 12/31/2299 O26872 Cervical shortening, second trimester 10/1/2015 12/31/2299 O26873 Cervical shortening, third trimester 10/1/2015 12/31/2299 O30001 Twin preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299 O30002 Twin preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30003 Twin preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30011 Twin pregnancy, monochorionic/monoamniotic, first trimester 10/1/2015 12/31/2299 Twin pregnancy, monochorionic/monoamniotic, second O30012 trimester 10/1/2015 12/31/2299 O30013 Twin pregnancy, monochorionic/monoamniotic, third trimester 10/1/2015 12/31/2299 O30031 Twin pregnancy, monochorionic/diamniotic, first trimester 10/1/2015 12/31/2299 O30032 Twin pregnancy, monochorionic/diamniotic, second trimester 10/1/2015 12/31/2299 O30033 Twin pregnancy, monochorionic/diamniotic, third trimester 10/1/2015 12/31/2299 O30041 Twin pregnancy, dichorionic/diamniotic, first trimester 10/1/2015 12/31/2299 O30042 Twin pregnancy, dichorionic/diamniotic, second trimester 10/1/2015 12/31/2299 O30043 Twin pregnancy, dichorionic/diamniotic, third trimester 10/1/2015 12/31/2299 O30091 Twin preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30093 Twin preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299
211 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O30101 Triplet preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299 O30102 Triplet preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30103 Triplet preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30111 Triplet preg w two or more monochorionic fetuses, first tri 10/1/2015 12/31/2299 O30112 Triplet preg w two or more monochorionic fetuses, second tri 10/1/2015 12/31/2299 O30113 Triplet preg w two or more monochorionic fetuses, third tri 10/1/2015 12/31/2299 O30121 Triplet preg w two or more monoamnio fetuses, first tri 10/1/2015 12/31/2299 O30122 Triplet preg w two or more monoamnio fetuses, second tri 10/1/2015 12/31/2299 O30123 Triplet preg w two or more monoamnio fetuses, third tri 10/1/2015 12/31/2299 O30131 Triplet pregnancy trichorionic/triamniotic first trimester 10/1/2018 12/31/2299 O30132 Triplet preg trichorionic/triamniotic second trimester 10/1/2018 12/31/2299 O30133 Triplet pregnancy trichorionic/triamniotic third trimester 10/1/2018 12/31/2299 O30139 Triplet pregnancy trichorionic/triamniotic unsp trimester 10/1/2018 12/31/2299 O30191 Trp preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30192 Trp preg, unable to dtrm num plcnta & amnio sacs, second tri 10/1/2015 12/31/2299 O30193 Trp preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299 O30201 Quad preg, unsp num plcnta & amnio sacs, first trimester 10/1/2015 12/31/2299 O30202 Quad preg, unsp num plcnta & amnio sacs, second trimester 10/1/2015 12/31/2299 O30203 Quad preg, unsp num plcnta & amnio sacs, third trimester 10/1/2015 12/31/2299 O30211 Quad preg w two or more monochorionic fetuses, first tri 10/1/2015 12/31/2299 O30212 Quad preg w two or more monochorionic fetuses, second tri 10/1/2015 12/31/2299 O30213 Quad preg w two or more monochorionic fetuses, third tri 10/1/2015 12/31/2299 O30221 Quad preg w two or more monoamnio fetuses, first trimester 10/1/2015 12/31/2299 O30222 Quad preg w two or more monoamnio fetuses, second trimester 10/1/2015 12/31/2299 O30223 Quad preg w two or more monoamnio fetuses, third trimester 10/1/2015 12/31/2299 O30231 Quad preg quadrachorionic/quadra-amniotic first trimester 10/1/2018 12/31/2299 O30232 Quad preg quadrachorionic/quadra-amniotic second trimester 10/1/2018 12/31/2299 O30233 Quad preg quadrachorionic/quadra-amniotic third trimester 10/1/2018 12/31/2299 O30239 Quad preg quadrachorionic/quadra-amniotic unsp trimester 10/1/2018 12/31/2299 O30291 Quad preg, unable to dtrm num plcnta & amnio sacs, first tri 10/1/2015 12/31/2299 O30292 Quad preg, unable to dtrm num plcnta & amnio sacs, 2nd tri 10/1/2015 12/31/2299 O30293 Quad preg, unable to dtrm num plcnta & amnio sacs, third tri 10/1/2015 12/31/2299
212 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O30831 Oth mult gest num chorions & amnions = num ftses 1st tri 10/1/2018 12/31/2299 O30832 Oth mult gest num chorions & amnions = num ftses 2nd tri 10/1/2018 12/31/2299 O30833 Oth mult gest num chorions & amnions = num ftses 3rd tri 10/1/2018 12/31/2299 O30839 Oth mult gest num chorions & amnions = num ftses unsp tri 10/1/2018 12/31/2299 O3111X0 Cont preg aft spon abort of one fts or more, first tri, unsp 10/1/2015 12/31/2299 O3111X1 Cont preg aft spon abort of one fts or more, first tri, fts1 10/1/2015 12/31/2299 O3111X2 Cont preg aft spon abort of one fts or more, first tri, fts2 10/1/2015 12/31/2299 O3111X3 Cont preg aft spon abort of one fts or more, first tri, fts3 10/1/2015 12/31/2299 O3111X4 Cont preg aft spon abort of one fts or more, first tri, fts4 10/1/2015 12/31/2299 O3111X5 Cont preg aft spon abort of one fts or more, first tri, fts5 10/1/2015 12/31/2299 O3111X9 Cont preg aft spon abort of one fts or more, first tri, oth 10/1/2015 12/31/2299 O3112X0 Cont preg aft spon abort of one fetus or more, 2nd tri, unsp 10/1/2015 12/31/2299 O3112X1 Cont preg aft spon abort of one fetus or more, 2nd tri, fts1 10/1/2015 12/31/2299 O3112X2 Cont preg aft spon abort of one fetus or more, 2nd tri, fts2 10/1/2015 12/31/2299 O3112X3 Cont preg aft spon abort of one fetus or more, 2nd tri, fts3 10/1/2015 12/31/2299 O3112X4 Cont preg aft spon abort of one fetus or more, 2nd tri, fts4 10/1/2015 12/31/2299 O3112X5 Cont preg aft spon abort of one fetus or more, 2nd tri, fts5 10/1/2015 12/31/2299 O3112X9 Cont preg aft spon abort of one fetus or more, 2nd tri, oth 10/1/2015 12/31/2299 O3113X0 Cont preg aft spon abort of one fts or more, third tri, unsp 10/1/2015 12/31/2299 O3113X1 Cont preg aft spon abort of one fts or more, third tri, fts1 10/1/2015 12/31/2299 O3113X2 Cont preg aft spon abort of one fts or more, third tri, fts2 10/1/2015 12/31/2299 O3113X3 Cont preg aft spon abort of one fts or more, third tri, fts3 10/1/2015 12/31/2299 O3113X4 Cont preg aft spon abort of one fts or more, third tri, fts4 10/1/2015 12/31/2299 O3113X5 Cont preg aft spon abort of one fts or more, third tri, fts5 10/1/2015 12/31/2299 O3113X9 Cont preg aft spon abort of one fts or more, third tri, oth 10/1/2015 12/31/2299 O3121X0 Cont preg aft uterin dth of one fts or more, first tri, unsp 10/1/2015 12/31/2299 O3121X1 Cont preg aft uterin dth of one fts or more, first tri, fts1 10/1/2015 12/31/2299 O3121X2 Cont preg aft uterin dth of one fts or more, first tri, fts2 10/1/2015 12/31/2299 O3121X3 Cont preg aft uterin dth of one fts or more, first tri, fts3 10/1/2015 12/31/2299 O3121X4 Cont preg aft uterin dth of one fts or more, first tri, fts4 10/1/2015 12/31/2299 O3121X5 Cont preg aft uterin dth of one fts or more, first tri, fts5 10/1/2015 12/31/2299 O3121X9 Cont preg aft uterin dth of one fts or more, first tri, oth 10/1/2015 12/31/2299
213 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O3122X0 Cont preg aft uterin dth of one fetus or more, 2nd tri, unsp 10/1/2015 12/31/2299 O3122X1 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts1 10/1/2015 12/31/2299 O3122X2 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts2 10/1/2015 12/31/2299 O3122X3 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts3 10/1/2015 12/31/2299 O3122X4 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts4 10/1/2015 12/31/2299 O3122X5 Cont preg aft uterin dth of one fetus or more, 2nd tri, fts5 10/1/2015 12/31/2299 O3122X9 Cont preg aft uterin dth of one fetus or more, 2nd tri, oth 10/1/2015 12/31/2299 O3123X0 Cont preg aft uterin dth of one fts or more, third tri, unsp 10/1/2015 12/31/2299 O3123X1 Cont preg aft uterin dth of one fts or more, third tri, fts1 10/1/2015 12/31/2299 O3123X2 Cont preg aft uterin dth of one fts or more, third tri, fts2 10/1/2015 12/31/2299 O3123X3 Cont preg aft uterin dth of one fts or more, third tri, fts3 10/1/2015 12/31/2299 O3123X4 Cont preg aft uterin dth of one fts or more, third tri, fts4 10/1/2015 12/31/2299 O3123X5 Cont preg aft uterin dth of one fts or more, third tri, fts5 10/1/2015 12/31/2299 O3123X9 Cont preg aft uterin dth of one fts or more, third tri, oth 10/1/2015 12/31/2299 O3131X0 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, unsp 10/1/2015 12/31/2299 O3131X1 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts1 10/1/2015 12/31/2299 O3131X2 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts2 10/1/2015 12/31/2299 O3131X3 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts3 10/1/2015 12/31/2299 O3131X4 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts4 10/1/2015 12/31/2299 O3131X5 Cont preg aft elctv fetl rdct of 1 fts or more,1st tri, fts5 10/1/2015 12/31/2299 O3131X9 Cont preg aft elctv fetl rdct of 1 fts or more, 1st tri, oth 10/1/2015 12/31/2299 O3132X0 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, unsp 10/1/2015 12/31/2299 O3132X1 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts1 10/1/2015 12/31/2299 O3132X2 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts2 10/1/2015 12/31/2299 O3132X3 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts3 10/1/2015 12/31/2299 O3132X4 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts4 10/1/2015 12/31/2299 O3132X5 Cont preg aft elctv fetl rdct of 1 fts or more,2nd tri, fts5 10/1/2015 12/31/2299 O3132X9 Cont preg aft elctv fetl rdct of 1 fts or more, 2nd tri, oth 10/1/2015 12/31/2299 O3133X0 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, unsp 10/1/2015 12/31/2299 O3133X1 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts1 10/1/2015 12/31/2299 O3133X2 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts2 10/1/2015 12/31/2299 O3133X3 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts3 10/1/2015 12/31/2299
214 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O3133X4 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts4 10/1/2015 12/31/2299 O3133X5 Cont preg aft elctv fetl rdct of 1 fts or more,3rd tri, fts5 10/1/2015 12/31/2299 O3133X9 Cont preg aft elctv fetl rdct of 1 fts or more, 3rd tri, oth 10/1/2015 12/31/2299 O320XX0 Maternal care for unstable lie, not applicable or unsp 10/1/2015 12/31/2299 O320XX1 Maternal care for unstable lie, fetus 1 10/1/2015 12/31/2299 O320XX2 Maternal care for unstable lie, fetus 2 10/1/2015 12/31/2299 O320XX3 Maternal care for unstable lie, fetus 3 10/1/2015 12/31/2299 O320XX4 Maternal care for unstable lie, fetus 4 10/1/2015 12/31/2299 O320XX5 Maternal care for unstable lie, fetus 5 10/1/2015 12/31/2299 O320XX9 Maternal care for unstable lie, other fetus 10/1/2015 12/31/2299 O321XX0 Maternal care for breech presentation, unsp 10/1/2015 12/31/2299 O321XX1 Maternal care for breech presentation, fetus 1 10/1/2015 12/31/2299 O321XX2 Maternal care for breech presentation, fetus 2 10/1/2015 12/31/2299 O321XX3 Maternal care for breech presentation, fetus 3 10/1/2015 12/31/2299 O321XX4 Maternal care for breech presentation, fetus 4 10/1/2015 12/31/2299 O321XX5 Maternal care for breech presentation, fetus 5 10/1/2015 12/31/2299 O321XX9 Maternal care for breech presentation, other fetus 10/1/2015 12/31/2299 O322XX0 Maternal care for transverse and oblique lie, unsp 10/1/2015 12/31/2299 O322XX1 Maternal care for transverse and oblique lie, fetus 1 10/1/2015 12/31/2299 O322XX2 Maternal care for transverse and oblique lie, fetus 2 10/1/2015 12/31/2299 O322XX3 Maternal care for transverse and oblique lie, fetus 3 10/1/2015 12/31/2299 O322XX4 Maternal care for transverse and oblique lie, fetus 4 10/1/2015 12/31/2299 O322XX5 Maternal care for transverse and oblique lie, fetus 5 10/1/2015 12/31/2299 O322XX9 Maternal care for transverse and oblique lie, other fetus 10/1/2015 12/31/2299 O323XX0 Maternal care for face, brow and chin presentation, unsp 10/1/2015 12/31/2299 O323XX1 Maternal care for face, brow and chin presentation, fetus 1 10/1/2015 12/31/2299 O323XX2 Maternal care for face, brow and chin presentation, fetus 2 10/1/2015 12/31/2299 O323XX3 Maternal care for face, brow and chin presentation, fetus 3 10/1/2015 12/31/2299 O323XX4 Maternal care for face, brow and chin presentation, fetus 4 10/1/2015 12/31/2299 O323XX5 Maternal care for face, brow and chin presentation, fetus 5 10/1/2015 12/31/2299 O323XX9 Maternal care for face, brow and chin presentation, oth 10/1/2015 12/31/2299 O324XX0 Maternal care for high head at term, not applicable or unsp 10/1/2015 12/31/2299
215 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O324XX1 Maternal care for high head at term, fetus 1 10/1/2015 12/31/2299 O324XX2 Maternal care for high head at term, fetus 2 10/1/2015 12/31/2299 O324XX3 Maternal care for high head at term, fetus 3 10/1/2015 12/31/2299 O324XX4 Maternal care for high head at term, fetus 4 10/1/2015 12/31/2299 O324XX5 Maternal care for high head at term, fetus 5 10/1/2015 12/31/2299 O324XX9 Maternal care for high head at term, other fetus 10/1/2015 12/31/2299 O328XX0 Maternal care for oth malpresentation of fetus, unsp 10/1/2015 12/31/2299 O329XX0 Maternal care for malpresentation of fetus, unsp, unsp 10/1/2015 12/31/2299 O330 Matern care for disproprtn d/t deformity of matern pelv bone 10/1/2015 12/31/2299 O331 Matern care for disproprtn d/t generally contracted pelvis 10/1/2015 12/31/2299 O332 Maternal care for disproprtn due to inlet contrctn of pelvis 10/1/2015 12/31/2299 O333XX0 Matern care for disproprtn d/t outlet contrctn of pelv, unsp 10/1/2015 12/31/2299 O333XX1 Matern care for disproprtn d/t outlet contrctn of pelv, fts1 10/1/2015 12/31/2299 O333XX2 Matern care for disproprtn d/t outlet contrctn of pelv, fts2 10/1/2015 12/31/2299 O333XX3 Matern care for disproprtn d/t outlet contrctn of pelv, fts3 10/1/2015 12/31/2299 O333XX4 Matern care for disproprtn d/t outlet contrctn of pelv, fts4 10/1/2015 12/31/2299 O333XX5 Matern care for disproprtn d/t outlet contrctn of pelv, fts5 10/1/2015 12/31/2299 O333XX9 Matern care for disproprtn d/t outlet contrctn of pelv, oth 10/1/2015 12/31/2299 O334XX0 Matern care for disproprtn of mix matern & fetl origin, unsp 10/1/2015 12/31/2299 O334XX1 Matern care for disproprtn of mix matern & fetl origin, fts1 10/1/2015 12/31/2299 O334XX2 Matern care for disproprtn of mix matern & fetl origin, fts2 10/1/2015 12/31/2299 O334XX3 Matern care for disproprtn of mix matern & fetl origin, fts3 10/1/2015 12/31/2299 O334XX4 Matern care for disproprtn of mix matern & fetl origin, fts4 10/1/2015 12/31/2299 O334XX5 Matern care for disproprtn of mix matern & fetl origin, fts5 10/1/2015 12/31/2299 O334XX9 Matern care for disproprtn of mix matern & fetl origin, oth 10/1/2015 12/31/2299 O335XX0 Matern care for disproprtn d/t unusually large fetus, unsp 10/1/2015 12/31/2299 O335XX1 Matern care for disproprtn d/t unusually large fetus, fts1 10/1/2015 12/31/2299 O335XX2 Matern care for disproprtn d/t unusually large fetus, fts2 10/1/2015 12/31/2299 O335XX3 Matern care for disproprtn d/t unusually large fetus, fts3 10/1/2015 12/31/2299 O335XX4 Matern care for disproprtn d/t unusually large fetus, fts4 10/1/2015 12/31/2299 O335XX5 Matern care for disproprtn d/t unusually large fetus, fts5 10/1/2015 12/31/2299 O335XX9 Matern care for disproprtn due to unusually large fetus, oth 10/1/2015 12/31/2299
216 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O336XX0 Matern care for disproprtn due to hydrocephalic fetus, unsp 10/1/2015 12/31/2299 O336XX1 Matern care for disproprtn due to hydrocephalic fetus, fts1 10/1/2015 12/31/2299 O336XX2 Matern care for disproprtn due to hydrocephalic fetus, fts2 10/1/2015 12/31/2299 O336XX3 Matern care for disproprtn due to hydrocephalic fetus, fts3 10/1/2015 12/31/2299 O336XX4 Matern care for disproprtn due to hydrocephalic fetus, fts4 10/1/2015 12/31/2299 O336XX5 Matern care for disproprtn due to hydrocephalic fetus, fts5 10/1/2015 12/31/2299 O336XX9 Maternal care for disproprtn due to hydrocephalic fetus, oth 10/1/2015 12/31/2299 O337 Maternal care for disproportion due to oth fetal deformities 10/1/2015 9/30/2016 O337XX0 Maternal care for disproprtn due to other fetal deform, unsp 10/1/2016 12/31/2299 O337XX1 Matern care for disproprtn due to other fetal deform, fts1 10/1/2016 12/31/2299 O337XX2 Matern care for disproprtn due to other fetal deform, fts2 10/1/2016 12/31/2299 O337XX3 Matern care for disproprtn due to other fetal deform, fts3 10/1/2016 12/31/2299 O337XX4 Matern care for disproprtn due to other fetal deform, fts4 10/1/2016 12/31/2299 O337XX5 Matern care for disproprtn due to other fetal deform, fts5 10/1/2016 12/31/2299 O337XX9 Maternal care for disproprtn due to other fetal deform, oth 10/1/2016 12/31/2299 O338 Maternal care for disproportion of other origin 10/1/2015 12/31/2299 O3401 Maternal care for unsp congen malform of uterus, first tri 10/1/2015 12/31/2299 O3402 Maternal care for unsp congen malform of uterus, second tri 10/1/2015 12/31/2299 O3403 Maternal care for unsp congen malform of uterus, third tri 10/1/2015 12/31/2299 O3411 Maternal care for benign tumor of corpus uteri, first tri 10/1/2015 12/31/2299 O3412 Maternal care for benign tumor of corpus uteri, second tri 10/1/2015 12/31/2299 O3413 Maternal care for benign tumor of corpus uteri, third tri 10/1/2015 12/31/2299 O3421 Maternal care for scar from previous cesarean delivery 10/1/2015 9/30/2016 O34211 Matern care for low transverse scar from prev cesarean del 10/1/2016 12/31/2299 O34212 Maternal care for vertical scar from previous cesarean del 10/1/2016 12/31/2299 O34219 Maternal care for unsp type scar from previous cesarean del 10/1/2016 12/31/2299 O3431 Maternal care for cervical incompetence, first trimester 10/1/2015 12/31/2299 O3432 Maternal care for cervical incompetence, second trimester 10/1/2015 12/31/2299 O3433 Maternal care for cervical incompetence, third trimester 10/1/2015 12/31/2299 O3441 Maternal care for oth abnlt of cervix, first trimester 10/1/2015 12/31/2299 O3442 Maternal care for oth abnlt of cervix, second trimester 10/1/2015 12/31/2299 O3443 Maternal care for oth abnlt of cervix, third trimester 10/1/2015 12/31/2299
217 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O34511 Maternal care for incarceration of gravid uterus, first tri 10/1/2015 12/31/2299 O34512 Maternal care for incarceration of gravid uterus, second tri 10/1/2015 12/31/2299 O34513 Maternal care for incarceration of gravid uterus, third tri 10/1/2015 12/31/2299 O34521 Maternal care for prolapse of gravid uterus, first trimester 10/1/2015 12/31/2299 O34522 Maternal care for prolapse of gravid uterus, second tri 10/1/2015 12/31/2299 O34523 Maternal care for prolapse of gravid uterus, third trimester 10/1/2015 12/31/2299 O34531 Maternal care for retroversion of gravid uterus, first tri 10/1/2015 12/31/2299 O34532 Maternal care for retroversion of gravid uterus, second tri 10/1/2015 12/31/2299 O34533 Maternal care for retroversion of gravid uterus, third tri 10/1/2015 12/31/2299 O34591 Maternal care for oth abnlt of gravid uterus, first tri 10/1/2015 12/31/2299 O34592 Maternal care for oth abnlt of gravid uterus, second tri 10/1/2015 12/31/2299 O34593 Maternal care for oth abnlt of gravid uterus, third tri 10/1/2015 12/31/2299 O3461 Maternal care for abnormality of vagina, first trimester 10/1/2015 12/31/2299 O3462 Maternal care for abnormality of vagina, second trimester 10/1/2015 12/31/2299 O3463 Maternal care for abnormality of vagina, third trimester 10/1/2015 12/31/2299 O3471 Maternal care for abnlt of vulva and perineum, first tri 10/1/2015 12/31/2299 O3472 Maternal care for abnlt of vulva and perineum, second tri 10/1/2015 12/31/2299 O3473 Maternal care for abnlt of vulva and perineum, third tri 10/1/2015 12/31/2299 O350XX0 Maternal care for (suspected) cnsl malform in fetus, unsp 10/1/2015 12/31/2299 O350XX1 Maternal care for (suspected) cnsl malform in fetus, fetus 1 10/1/2015 12/31/2299 O350XX2 Maternal care for (suspected) cnsl malform in fetus, fetus 2 10/1/2015 12/31/2299 O350XX3 Maternal care for (suspected) cnsl malform in fetus, fetus 3 10/1/2015 12/31/2299 O350XX4 Maternal care for (suspected) cnsl malform in fetus, fetus 4 10/1/2015 12/31/2299 O350XX5 Maternal care for (suspected) cnsl malform in fetus, fetus 5 10/1/2015 12/31/2299 O350XX9 Maternal care for (suspected) cnsl malform in fetus, oth 10/1/2015 12/31/2299 O351XX0 Maternal care for chromosomal abnormality in fetus, unsp 10/1/2015 12/31/2299 O351XX1 Maternal care for chromosomal abnormality in fetus, fetus 1 10/1/2015 12/31/2299 O351XX2 Maternal care for chromosomal abnormality in fetus, fetus 2 10/1/2015 12/31/2299 O351XX3 Maternal care for chromosomal abnormality in fetus, fetus 3 10/1/2015 12/31/2299 O351XX4 Maternal care for chromosomal abnormality in fetus, fetus 4 10/1/2015 12/31/2299 O351XX5 Maternal care for chromosomal abnormality in fetus, fetus 5 10/1/2015 12/31/2299 O351XX9 Maternal care for chromosomal abnormality in fetus, oth 10/1/2015 12/31/2299
218 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O353XX0 Matern care for damag to fts from viral dis in mother, unsp 10/1/2015 12/31/2299 O353XX1 Matern care for damag to fts from viral dis in mother, fts1 10/1/2015 12/31/2299 O353XX2 Matern care for damag to fts from viral dis in mother, fts2 10/1/2015 12/31/2299 O353XX3 Matern care for damag to fts from viral dis in mother, fts3 10/1/2015 12/31/2299 O353XX4 Matern care for damag to fts from viral dis in mother, fts4 10/1/2015 12/31/2299 O353XX5 Matern care for damag to fts from viral dis in mother, fts5 10/1/2015 12/31/2299 O353XX9 Matern care for damag to fetus from viral dis in mother, oth 10/1/2015 12/31/2299 O354XX0 Maternal care for damage to fetus from alcohol, unsp 10/1/2015 12/31/2299 O354XX1 Maternal care for damage to fetus from alcohol, fetus 1 10/1/2015 12/31/2299 O354XX2 Maternal care for damage to fetus from alcohol, fetus 2 10/1/2015 12/31/2299 O354XX3 Maternal care for damage to fetus from alcohol, fetus 3 10/1/2015 12/31/2299 O354XX4 Maternal care for damage to fetus from alcohol, fetus 4 10/1/2015 12/31/2299 O354XX5 Maternal care for damage to fetus from alcohol, fetus 5 10/1/2015 12/31/2299 O354XX9 Maternal care for damage to fetus from alcohol, oth 10/1/2015 12/31/2299 O355XX0 Maternal care for (suspected) damage to fetus by drugs, unsp 10/1/2015 12/31/2299 O355XX1 Maternal care for damage to fetus by drugs, fetus 1 10/1/2015 12/31/2299 O355XX2 Maternal care for damage to fetus by drugs, fetus 2 10/1/2015 12/31/2299 O355XX3 Maternal care for damage to fetus by drugs, fetus 3 10/1/2015 12/31/2299 O355XX4 Maternal care for damage to fetus by drugs, fetus 4 10/1/2015 12/31/2299 O355XX5 Maternal care for damage to fetus by drugs, fetus 5 10/1/2015 12/31/2299 O355XX9 Maternal care for (suspected) damage to fetus by drugs, oth 10/1/2015 12/31/2299 O356XX0 Maternal care for damage to fetus by radiation, unsp 10/1/2015 12/31/2299 O356XX1 Maternal care for damage to fetus by radiation, fetus 1 10/1/2015 12/31/2299 O356XX2 Maternal care for damage to fetus by radiation, fetus 2 10/1/2015 12/31/2299 O356XX3 Maternal care for damage to fetus by radiation, fetus 3 10/1/2015 12/31/2299 O356XX4 Maternal care for damage to fetus by radiation, fetus 4 10/1/2015 12/31/2299 O356XX5 Maternal care for damage to fetus by radiation, fetus 5 10/1/2015 12/31/2299 O356XX9 Maternal care for damage to fetus by radiation, oth 10/1/2015 12/31/2299 O358XX0 Maternal care for oth fetal abnormality and damage, unsp 10/1/2015 12/31/2299 O358XX1 Maternal care for oth fetal abnormality and damage, fetus 1 10/1/2015 12/31/2299 O358XX2 Maternal care for oth fetal abnormality and damage, fetus 2 10/1/2015 12/31/2299 O358XX3 Maternal care for oth fetal abnormality and damage, fetus 3 10/1/2015 12/31/2299
219 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O358XX4 Maternal care for oth fetal abnormality and damage, fetus 4 10/1/2015 12/31/2299 O358XX5 Maternal care for oth fetal abnormality and damage, fetus 5 10/1/2015 12/31/2299 O358XX9 Maternal care for oth fetal abnormality and damage, oth 10/1/2015 12/31/2299 O359XX0 Maternal care for fetal abnormality and damage, unsp, unsp 01/01/2019 12/31/2299 O360110 Maternal care for anti-D antibodies, first trimester, unsp 10/1/2015 12/31/2299 O360111 Maternal care for anti-D antibodies, first tri, fetus 1 10/1/2015 12/31/2299 O360112 Maternal care for anti-D antibodies, first tri, fetus 2 10/1/2015 12/31/2299 O360113 Maternal care for anti-D antibodies, first tri, fetus 3 10/1/2015 12/31/2299 O360114 Maternal care for anti-D antibodies, first tri, fetus 4 10/1/2015 12/31/2299 O360115 Maternal care for anti-D antibodies, first tri, fetus 5 10/1/2015 12/31/2299 O360119 Maternal care for anti-D antibodies, first trimester, oth 10/1/2015 12/31/2299 O360120 Maternal care for anti-D antibodies, second trimester, unsp 10/1/2015 12/31/2299 O360121 Maternal care for anti-D antibodies, second tri, fetus 1 10/1/2015 12/31/2299 O360122 Maternal care for anti-D antibodies, second tri, fetus 2 10/1/2015 12/31/2299 O360123 Maternal care for anti-D antibodies, second tri, fetus 3 10/1/2015 12/31/2299 O360124 Maternal care for anti-D antibodies, second tri, fetus 4 10/1/2015 12/31/2299 O360125 Maternal care for anti-D antibodies, second tri, fetus 5 10/1/2015 12/31/2299 O360129 Maternal care for anti-D antibodies, second trimester, oth 10/1/2015 12/31/2299 O360130 Maternal care for anti-D antibodies, third trimester, unsp 10/1/2015 12/31/2299 O360131 Maternal care for anti-D antibodies, third tri, fetus 1 10/1/2015 12/31/2299 O360132 Maternal care for anti-D antibodies, third tri, fetus 2 10/1/2015 12/31/2299 O360133 Maternal care for anti-D antibodies, third tri, fetus 3 10/1/2015 12/31/2299 O360134 Maternal care for anti-D antibodies, third tri, fetus 4 10/1/2015 12/31/2299 O360135 Maternal care for anti-D antibodies, third tri, fetus 5 10/1/2015 12/31/2299 O360139 Maternal care for anti-D antibodies, third trimester, oth 10/1/2015 12/31/2299 O360910 Maternal care for oth rhesus isoimmun, first trimester, unsp 10/1/2015 12/31/2299 O360911 Maternal care for oth rhesus isoimmun, first tri, fetus 1 10/1/2015 12/31/2299 O360912 Maternal care for oth rhesus isoimmun, first tri, fetus 2 10/1/2015 12/31/2299 O360913 Maternal care for oth rhesus isoimmun, first tri, fetus 3 10/1/2015 12/31/2299 O360914 Maternal care for oth rhesus isoimmun, first tri, fetus 4 10/1/2015 12/31/2299 O360915 Maternal care for oth rhesus isoimmun, first tri, fetus 5 10/1/2015 12/31/2299 O360919 Maternal care for oth rhesus isoimmun, first trimester, oth 10/1/2015 12/31/2299
220 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O360920 Maternal care for oth rhesus isoimmun, second tri, unsp 10/1/2015 12/31/2299 O360921 Maternal care for oth rhesus isoimmun, second tri, fetus 1 10/1/2015 12/31/2299 O360922 Maternal care for oth rhesus isoimmun, second tri, fetus 2 10/1/2015 12/31/2299 O360923 Maternal care for oth rhesus isoimmun, second tri, fetus 3 10/1/2015 12/31/2299 O360924 Maternal care for oth rhesus isoimmun, second tri, fetus 4 10/1/2015 12/31/2299 O360925 Maternal care for oth rhesus isoimmun, second tri, fetus 5 10/1/2015 12/31/2299 O360929 Maternal care for oth rhesus isoimmun, second trimester, oth 10/1/2015 12/31/2299 O360930 Maternal care for oth rhesus isoimmun, third trimester, unsp 10/1/2015 12/31/2299 O360931 Maternal care for oth rhesus isoimmun, third tri, fetus 1 10/1/2015 12/31/2299 O360932 Maternal care for oth rhesus isoimmun, third tri, fetus 2 10/1/2015 12/31/2299 O360933 Maternal care for oth rhesus isoimmun, third tri, fetus 3 10/1/2015 12/31/2299 O360934 Maternal care for oth rhesus isoimmun, third tri, fetus 4 10/1/2015 12/31/2299 O360935 Maternal care for oth rhesus isoimmun, third tri, fetus 5 10/1/2015 12/31/2299 O360939 Maternal care for oth rhesus isoimmun, third trimester, oth 10/1/2015 12/31/2299 O361110 Maternal care for Anti-A sensitization, first tri, unsp 10/1/2015 12/31/2299 O361111 Maternal care for Anti-A sensitization, first tri, fetus 1 10/1/2015 12/31/2299 O361112 Maternal care for Anti-A sensitization, first tri, fetus 2 10/1/2015 12/31/2299 O361113 Maternal care for Anti-A sensitization, first tri, fetus 3 10/1/2015 12/31/2299 O361114 Maternal care for Anti-A sensitization, first tri, fetus 4 10/1/2015 12/31/2299 O361115 Maternal care for Anti-A sensitization, first tri, fetus 5 10/1/2015 12/31/2299 O361119 Maternal care for Anti-A sensitization, first trimester, oth 10/1/2015 12/31/2299 O361120 Maternal care for Anti-A sensitization, second tri, unsp 10/1/2015 12/31/2299 O361121 Maternal care for Anti-A sensitization, second tri, fetus 1 10/1/2015 12/31/2299 O361122 Maternal care for Anti-A sensitization, second tri, fetus 2 10/1/2015 12/31/2299 O361123 Maternal care for Anti-A sensitization, second tri, fetus 3 10/1/2015 12/31/2299 O361124 Maternal care for Anti-A sensitization, second tri, fetus 4 10/1/2015 12/31/2299 O361125 Maternal care for Anti-A sensitization, second tri, fetus 5 10/1/2015 12/31/2299 O361129 Maternal care for Anti-A sensitization, second tri, oth 10/1/2015 12/31/2299 O361130 Maternal care for Anti-A sensitization, third tri, unsp 10/1/2015 12/31/2299 O361131 Maternal care for Anti-A sensitization, third tri, fetus 1 10/1/2015 12/31/2299 O361132 Maternal care for Anti-A sensitization, third tri, fetus 2 10/1/2015 12/31/2299 O361133 Maternal care for Anti-A sensitization, third tri, fetus 3 10/1/2015 12/31/2299
221 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O361134 Maternal care for Anti-A sensitization, third tri, fetus 4 10/1/2015 12/31/2299 O361135 Maternal care for Anti-A sensitization, third tri, fetus 5 10/1/2015 12/31/2299 O361139 Maternal care for Anti-A sensitization, third trimester, oth 10/1/2015 12/31/2299 O361910 Maternal care for oth isoimmunization, first trimester, unsp 10/1/2015 12/31/2299 O361911 Maternal care for oth isoimmun, first trimester, fetus 1 10/1/2015 12/31/2299 O361912 Maternal care for oth isoimmun, first trimester, fetus 2 10/1/2015 12/31/2299 O361913 Maternal care for oth isoimmun, first trimester, fetus 3 10/1/2015 12/31/2299 O361914 Maternal care for oth isoimmun, first trimester, fetus 4 10/1/2015 12/31/2299 O361915 Maternal care for oth isoimmun, first trimester, fetus 5 10/1/2015 12/31/2299 O361919 Maternal care for oth isoimmunization, first trimester, oth 10/1/2015 12/31/2299 O361920 Maternal care for oth isoimmun, second trimester, unsp 10/1/2015 12/31/2299 O361921 Maternal care for oth isoimmun, second trimester, fetus 1 10/1/2015 12/31/2299 O361922 Maternal care for oth isoimmun, second trimester, fetus 2 10/1/2015 12/31/2299 O361923 Maternal care for oth isoimmun, second trimester, fetus 3 10/1/2015 12/31/2299 O361924 Maternal care for oth isoimmun, second trimester, fetus 4 10/1/2015 12/31/2299 O361925 Maternal care for oth isoimmun, second trimester, fetus 5 10/1/2015 12/31/2299 O361929 Maternal care for oth isoimmunization, second trimester, oth 10/1/2015 12/31/2299 O361930 Maternal care for oth isoimmunization, third trimester, unsp 10/1/2015 12/31/2299 O361931 Maternal care for oth isoimmun, third trimester, fetus 1 10/1/2015 12/31/2299 O361932 Maternal care for oth isoimmun, third trimester, fetus 2 10/1/2015 12/31/2299 O361933 Maternal care for oth isoimmun, third trimester, fetus 3 10/1/2015 12/31/2299 O361934 Maternal care for oth isoimmun, third trimester, fetus 4 10/1/2015 12/31/2299 O361935 Maternal care for oth isoimmun, third trimester, fetus 5 10/1/2015 12/31/2299 O361939 Maternal care for oth isoimmunization, third trimester, oth 10/1/2015 12/31/2299 O3621X0 Maternal care for hydrops fetalis, first trimester, unsp 10/1/2015 12/31/2299 O3621X1 Maternal care for hydrops fetalis, first trimester, fetus 1 10/1/2015 12/31/2299 O3621X2 Maternal care for hydrops fetalis, first trimester, fetus 2 10/1/2015 12/31/2299 O3621X3 Maternal care for hydrops fetalis, first trimester, fetus 3 10/1/2015 12/31/2299 O3621X4 Maternal care for hydrops fetalis, first trimester, fetus 4 10/1/2015 12/31/2299 O3621X5 Maternal care for hydrops fetalis, first trimester, fetus 5 10/1/2015 12/31/2299 O3621X9 Maternal care for hydrops fetalis, first trimester, oth 10/1/2015 12/31/2299 O3622X0 Maternal care for hydrops fetalis, second trimester, unsp 10/1/2015 12/31/2299
222 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O3622X1 Maternal care for hydrops fetalis, second trimester, fetus 1 10/1/2015 12/31/2299 O3622X2 Maternal care for hydrops fetalis, second trimester, fetus 2 10/1/2015 12/31/2299 O3622X3 Maternal care for hydrops fetalis, second trimester, fetus 3 10/1/2015 12/31/2299 O3622X4 Maternal care for hydrops fetalis, second trimester, fetus 4 10/1/2015 12/31/2299 O3622X5 Maternal care for hydrops fetalis, second trimester, fetus 5 10/1/2015 12/31/2299 O3622X9 Maternal care for hydrops fetalis, second trimester, oth 10/1/2015 12/31/2299 O3623X0 Maternal care for hydrops fetalis, third trimester, unsp 10/1/2015 12/31/2299 O3623X1 Maternal care for hydrops fetalis, third trimester, fetus 1 10/1/2015 12/31/2299 O3623X2 Maternal care for hydrops fetalis, third trimester, fetus 2 10/1/2015 12/31/2299 O3623X3 Maternal care for hydrops fetalis, third trimester, fetus 3 10/1/2015 12/31/2299 O3623X4 Maternal care for hydrops fetalis, third trimester, fetus 4 10/1/2015 12/31/2299 O3623X5 Maternal care for hydrops fetalis, third trimester, fetus 5 10/1/2015 12/31/2299 O3623X9 Maternal care for hydrops fetalis, third trimester, oth 10/1/2015 12/31/2299 O364XX0 Maternal care for intrauterine death, not applicable or unsp 10/1/2015 12/31/2299 O364XX1 Maternal care for intrauterine death, fetus 1 10/1/2015 12/31/2299 O364XX2 Maternal care for intrauterine death, fetus 2 10/1/2015 12/31/2299 O364XX3 Maternal care for intrauterine death, fetus 3 10/1/2015 12/31/2299 O364XX4 Maternal care for intrauterine death, fetus 4 10/1/2015 12/31/2299 O364XX5 Maternal care for intrauterine death, fetus 5 10/1/2015 12/31/2299 O364XX9 Maternal care for intrauterine death, other fetus 10/1/2015 12/31/2299 O365110 Matern care for known or susp placntl insuff, 1st tri, unsp 10/1/2015 12/31/2299 O365111 Matern care for known or susp placntl insuff, 1st tri, fts1 10/1/2015 12/31/2299 O365112 Matern care for known or susp placntl insuff, 1st tri, fts2 10/1/2015 12/31/2299 O365113 Matern care for known or susp placntl insuff, 1st tri, fts3 10/1/2015 12/31/2299 O365114 Matern care for known or susp placntl insuff, 1st tri, fts4 10/1/2015 12/31/2299 O365115 Matern care for known or susp placntl insuff, 1st tri, fts5 10/1/2015 12/31/2299 O365119 Matern care for known or susp placntl insuff, first tri, oth 10/1/2015 12/31/2299 O365120 Matern care for known or susp placntl insuff, 2nd tri, unsp 10/1/2015 12/31/2299 O365121 Matern care for known or susp placntl insuff, 2nd tri, fts1 10/1/2015 12/31/2299 O365122 Matern care for known or susp placntl insuff, 2nd tri, fts2 10/1/2015 12/31/2299 O365123 Matern care for known or susp placntl insuff, 2nd tri, fts3 10/1/2015 12/31/2299 O365124 Matern care for known or susp placntl insuff, 2nd tri, fts4 10/1/2015 12/31/2299
223 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O365125 Matern care for known or susp placntl insuff, 2nd tri, fts5 10/1/2015 12/31/2299 O365129 Matern care for known or susp placntl insuff, 2nd tri, oth 10/1/2015 12/31/2299 O365130 Matern care for or susp placntl insuff, third tri, unsp 10/1/2015 12/31/2299 O365131 Matern care for or susp placntl insuff, third tri, fts1 10/1/2015 12/31/2299 O365132 Matern care for or susp placntl insuff, third tri, fts2 10/1/2015 12/31/2299 O365133 Matern care for or susp placntl insuff, third tri, fts3 10/1/2015 12/31/2299 O365134 Matern care for or susp placntl insuff, third tri, fts4 10/1/2015 12/31/2299 O365135 Matern care for or susp placntl insuff, third tri, fts5 10/1/2015 12/31/2299 O365139 Matern care for known or susp placntl insuff, third tri, oth 10/1/2015 12/31/2299 O365910 Matern care for oth or susp poor fetl grth, 1st tri, unsp 10/1/2015 12/31/2299 O365911 Matern care for oth or susp poor fetl grth, 1st tri, fts1 10/1/2015 12/31/2299 O365912 Matern care for oth or susp poor fetl grth, 1st tri, fts2 10/1/2015 12/31/2299 O365913 Matern care for oth or susp poor fetl grth, 1st tri, fts3 10/1/2015 12/31/2299 O365914 Matern care for oth or susp poor fetl grth, 1st tri, fts4 10/1/2015 12/31/2299 O365915 Matern care for oth or susp poor fetl grth, 1st tri, fts5 10/1/2015 12/31/2299 O365919 Matern care for oth or susp poor fetl grth, 1st tri, oth 10/1/2015 12/31/2299 O365920 Matern care for oth or susp poor fetl grth, 2nd tri, unsp 10/1/2015 12/31/2299 O365921 Matern care for oth or susp poor fetl grth, 2nd tri, fts1 10/1/2015 12/31/2299 O365922 Matern care for oth or susp poor fetl grth, 2nd tri, fts2 10/1/2015 12/31/2299 O365923 Matern care for oth or susp poor fetl grth, 2nd tri, fts3 10/1/2015 12/31/2299 O365924 Matern care for oth or susp poor fetl grth, 2nd tri, fts4 10/1/2015 12/31/2299 O365925 Matern care for oth or susp poor fetl grth, 2nd tri, fts5 10/1/2015 12/31/2299 O365929 Matern care for oth or susp poor fetl grth, 2nd tri, oth 10/1/2015 12/31/2299 O365930 Matern care for oth or susp poor fetl grth, third tri, unsp 10/1/2015 12/31/2299 O365931 Matern care for oth or susp poor fetl grth, third tri, fts1 10/1/2015 12/31/2299 O365932 Matern care for oth or susp poor fetl grth, third tri, fts2 10/1/2015 12/31/2299 O365933 Matern care for oth or susp poor fetl grth, third tri, fts3 10/1/2015 12/31/2299 O365934 Matern care for oth or susp poor fetl grth, third tri, fts4 10/1/2015 12/31/2299 O365935 Matern care for oth or susp poor fetl grth, third tri, fts5 10/1/2015 12/31/2299 O365939 Matern care for oth or susp poor fetl grth, third tri, oth 10/1/2015 12/31/2299 O3661X0 Maternal care for excess fetal growth, first trimester, unsp 10/1/2015 12/31/2299 O3661X1 Maternal care for excess fetal growth, first tri, fetus 1 10/1/2015 12/31/2299
224 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O3661X2 Maternal care for excess fetal growth, first tri, fetus 2 10/1/2015 12/31/2299 O3661X3 Maternal care for excess fetal growth, first tri, fetus 3 10/1/2015 12/31/2299 O3661X4 Maternal care for excess fetal growth, first tri, fetus 4 10/1/2015 12/31/2299 O3661X5 Maternal care for excess fetal growth, first tri, fetus 5 10/1/2015 12/31/2299 O3661X9 Maternal care for excess fetal growth, first trimester, oth 10/1/2015 12/31/2299 O3662X0 Maternal care for excess fetal growth, second tri, unsp 10/1/2015 12/31/2299 O3662X1 Maternal care for excess fetal growth, second tri, fetus 1 10/1/2015 12/31/2299 O3662X2 Maternal care for excess fetal growth, second tri, fetus 2 10/1/2015 12/31/2299 O3662X3 Maternal care for excess fetal growth, second tri, fetus 3 10/1/2015 12/31/2299 O3662X4 Maternal care for excess fetal growth, second tri, fetus 4 10/1/2015 12/31/2299 O3662X5 Maternal care for excess fetal growth, second tri, fetus 5 10/1/2015 12/31/2299 O3662X9 Maternal care for excess fetal growth, second trimester, oth 10/1/2015 12/31/2299 O3663X0 Maternal care for excess fetal growth, third trimester, unsp 10/1/2015 12/31/2299 O3663X1 Maternal care for excess fetal growth, third tri, fetus 1 10/1/2015 12/31/2299 O3663X2 Maternal care for excess fetal growth, third tri, fetus 2 10/1/2015 12/31/2299 O3663X3 Maternal care for excess fetal growth, third tri, fetus 3 10/1/2015 12/31/2299 O3663X4 Maternal care for excess fetal growth, third tri, fetus 4 10/1/2015 12/31/2299 O3663X5 Maternal care for excess fetal growth, third tri, fetus 5 10/1/2015 12/31/2299 O3663X9 Maternal care for excess fetal growth, third trimester, oth 10/1/2015 12/31/2299 O3671X0 Maternal care for viable fetus in abd preg, first tri, unsp 10/1/2015 12/31/2299 O3671X1 Matern care for viable fetus in abd preg, first tri, fetus 1 10/1/2015 12/31/2299 O3671X2 Matern care for viable fetus in abd preg, first tri, fetus 2 10/1/2015 12/31/2299 O3671X3 Matern care for viable fetus in abd preg, first tri, fetus 3 10/1/2015 12/31/2299 O3671X4 Matern care for viable fetus in abd preg, first tri, fetus 4 10/1/2015 12/31/2299 O3671X5 Matern care for viable fetus in abd preg, first tri, fetus 5 10/1/2015 12/31/2299 O3671X9 Maternal care for viable fetus in abd preg, first tri, oth 10/1/2015 12/31/2299 O3672X0 Maternal care for viable fetus in abd preg, second tri, unsp 10/1/2015 12/31/2299 O3672X1 Matern care for viable fetus in abd preg, second tri, fts1 10/1/2015 12/31/2299 O3672X2 Matern care for viable fetus in abd preg, second tri, fts2 10/1/2015 12/31/2299 O3672X3 Matern care for viable fetus in abd preg, second tri, fts3 10/1/2015 12/31/2299 O3672X4 Matern care for viable fetus in abd preg, second tri, fts4 10/1/2015 12/31/2299 O3672X5 Matern care for viable fetus in abd preg, second tri, fts5 10/1/2015 12/31/2299
225 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O3672X9 Maternal care for viable fetus in abd preg, second tri, oth 10/1/2015 12/31/2299 O3673X0 Maternal care for viable fetus in abd preg, third tri, unsp 10/1/2015 12/31/2299 O3673X1 Matern care for viable fetus in abd preg, third tri, fetus 1 10/1/2015 12/31/2299 O3673X2 Matern care for viable fetus in abd preg, third tri, fetus 2 10/1/2015 12/31/2299 O3673X3 Matern care for viable fetus in abd preg, third tri, fetus 3 10/1/2015 12/31/2299 O3673X4 Matern care for viable fetus in abd preg, third tri, fetus 4 10/1/2015 12/31/2299 O3673X5 Matern care for viable fetus in abd preg, third tri, fetus 5 10/1/2015 12/31/2299 O3673X9 Maternal care for viable fetus in abd preg, third tri, oth 10/1/2015 12/31/2299 O3680X0 Pregnancy w inconclusive fetal viability, unsp 10/1/2015 12/31/2299 O3680X1 Pregnancy with inconclusive fetal viability, fetus 1 10/1/2015 12/31/2299 O3680X2 Pregnancy with inconclusive fetal viability, fetus 2 10/1/2015 12/31/2299 O3680X3 Pregnancy with inconclusive fetal viability, fetus 3 10/1/2015 12/31/2299 O3680X4 Pregnancy with inconclusive fetal viability, fetus 4 10/1/2015 12/31/2299 O3680X5 Pregnancy with inconclusive fetal viability, fetus 5 10/1/2015 12/31/2299 O3680X9 Pregnancy with inconclusive fetal viability, other fetus 10/1/2015 12/31/2299 O368120 Decreased fetal movements, second trimester, unsp 10/1/2015 12/31/2299 O368121 Decreased fetal movements, second trimester, fetus 1 10/1/2015 12/31/2299 O368122 Decreased fetal movements, second trimester, fetus 2 10/1/2015 12/31/2299 O368123 Decreased fetal movements, second trimester, fetus 3 10/1/2015 12/31/2299 O368124 Decreased fetal movements, second trimester, fetus 4 10/1/2015 12/31/2299 O368125 Decreased fetal movements, second trimester, fetus 5 10/1/2015 12/31/2299 O368129 Decreased fetal movements, second trimester, other fetus 10/1/2015 12/31/2299 O368130 Decreased fetal movements, third trimester, unsp 10/1/2015 12/31/2299 O368131 Decreased fetal movements, third trimester, fetus 1 10/1/2015 12/31/2299 O368132 Decreased fetal movements, third trimester, fetus 2 10/1/2015 12/31/2299 O368133 Decreased fetal movements, third trimester, fetus 3 10/1/2015 12/31/2299 O368134 Decreased fetal movements, third trimester, fetus 4 10/1/2015 12/31/2299 O368135 Decreased fetal movements, third trimester, fetus 5 10/1/2015 12/31/2299 O368139 Decreased fetal movements, third trimester, other fetus 10/1/2015 12/31/2299 O368190 Decreased fetal movements, unsp trimester, unsp 10/1/2015 12/31/2299 O368191 Decreased fetal movements, unspecified trimester, fetus 1 10/1/2015 12/31/2299 O368192 Decreased fetal movements, unspecified trimester, fetus 2 10/1/2015 12/31/2299
226 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O368193 Decreased fetal movements, unspecified trimester, fetus 3 10/1/2015 12/31/2299 O368194 Decreased fetal movements, unspecified trimester, fetus 4 10/1/2015 12/31/2299 O368195 Decreased fetal movements, unspecified trimester, fetus 5 10/1/2015 12/31/2299 O368199 Decreased fetal movements, unsp trimester, other fetus 10/1/2015 12/31/2299 O368311 Matern care for abnlt fetl hrt rate or rhym 1st tri fts1 10/1/2017 12/31/2299 O368312 Matern care for abnlt fetl hrt rate or rhym 1st tri fts2 10/1/2017 12/31/2299 O368313 Matern care for abnlt fetl hrt rate or rhym 1st tri fts3 10/1/2017 12/31/2299 O368314 Matern care for abnlt fetl hrt rate or rhym 1st tri fts4 10/1/2017 12/31/2299 O368315 Matern care for abnlt fetl hrt rate or rhym 1st tri fts5 10/1/2017 12/31/2299 O368319 Matern care for abnlt of fetl hrt rate or rhym 1st tri oth 10/1/2017 12/31/2299 O368321 Matern care for abnlt fetl hrt rate or rhym 2nd tri fts1 10/1/2017 12/31/2299 O368322 Matern care for abnlt fetl hrt rate or rhym 2nd tri fts2 10/1/2017 12/31/2299 O368323 Matern care for abnlt fetl hrt rate or rhym 2nd tri fts3 10/1/2017 12/31/2299 O368324 Matern care for abnlt fetl hrt rate or rhym 2nd tri fts4 10/1/2017 12/31/2299 O368325 Matern care for abnlt fetl hrt rate or rhym 2nd tri fts5 10/1/2017 12/31/2299 O368329 Matern care for abnlt of fetl hrt rate or rhym 2nd tri oth 10/1/2017 12/31/2299 O368331 Matern care for abnlt fetl hrt rate or rhym 3rd tri fts1 10/1/2017 12/31/2299 O368332 Matern care for abnlt fetl hrt rate or rhym 3rd tri fts2 10/1/2017 12/31/2299 O368333 Matern care for abnlt fetl hrt rate or rhym 3rd tri fts3 10/1/2017 12/31/2299 O368334 Matern care for abnlt fetl hrt rate or rhym 3rd tri fts4 10/1/2017 12/31/2299 O368335 Matern care for abnlt fetl hrt rate or rhym 3rd tri fts5 10/1/2017 12/31/2299 O368339 Matern care for abnlt of fetl hrt rate or rhym 3rd tri oth 10/1/2017 12/31/2299 O368391 Matern care for abnlt fetl hrt rate or rhym unsp tri fts1 10/1/2017 12/31/2299 O368392 Matern care for abnlt fetl hrt rate or rhym unsp tri fts2 10/1/2017 12/31/2299 O368393 Matern care for abnlt fetl hrt rate or rhym unsp tri fts3 10/1/2017 12/31/2299 O368394 Matern care for abnlt fetl hrt rate or rhym unsp tri fts4 10/1/2017 12/31/2299 O368395 Matern care for abnlt fetl hrt rate or rhym unsp tri fts5 10/1/2017 12/31/2299 O368399 Matern care for abnlt fetl hrt rate or rhym unsp tri oth 10/1/2017 12/31/2299 O368910 Maternal care for oth fetal problems, first trimester, unsp 10/1/2015 12/31/2299 O368911 Maternal care for oth fetal problems, first tri, fetus 1 10/1/2015 12/31/2299 O368912 Maternal care for oth fetal problems, first tri, fetus 2 10/1/2015 12/31/2299 O368913 Maternal care for oth fetal problems, first tri, fetus 3 10/1/2015 12/31/2299
227 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O368914 Maternal care for oth fetal problems, first tri, fetus 4 10/1/2015 12/31/2299 O368915 Maternal care for oth fetal problems, first tri, fetus 5 10/1/2015 12/31/2299 O368919 Maternal care for oth fetal problems, first trimester, oth 10/1/2015 12/31/2299 O368920 Maternal care for oth fetal problems, second trimester, unsp 10/1/2015 12/31/2299 O368921 Maternal care for oth fetal problems, second tri, fetus 1 10/1/2015 12/31/2299 O368922 Maternal care for oth fetal problems, second tri, fetus 2 10/1/2015 12/31/2299 O368923 Maternal care for oth fetal problems, second tri, fetus 3 10/1/2015 12/31/2299 O368924 Maternal care for oth fetal problems, second tri, fetus 4 10/1/2015 12/31/2299 O368925 Maternal care for oth fetal problems, second tri, fetus 5 10/1/2015 12/31/2299 O368929 Maternal care for oth fetal problems, second trimester, oth 10/1/2015 12/31/2299 O368930 Maternal care for oth fetal problems, third trimester, unsp 10/1/2015 12/31/2299 O368931 Maternal care for oth fetal problems, third tri, fetus 1 10/1/2015 12/31/2299 O368932 Maternal care for oth fetal problems, third tri, fetus 2 10/1/2015 12/31/2299 O368933 Maternal care for oth fetal problems, third tri, fetus 3 10/1/2015 12/31/2299 O368934 Maternal care for oth fetal problems, third tri, fetus 4 10/1/2015 12/31/2299 O368935 Maternal care for oth fetal problems, third tri, fetus 5 10/1/2015 12/31/2299 O368939 Maternal care for oth fetal problems, third trimester, oth 10/1/2015 12/31/2299 O401XX0 Polyhydramnios, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O401XX1 Polyhydramnios, first trimester, fetus 1 10/1/2015 12/31/2299 O401XX2 Polyhydramnios, first trimester, fetus 2 10/1/2015 12/31/2299 O401XX3 Polyhydramnios, first trimester, fetus 3 10/1/2015 12/31/2299 O401XX4 Polyhydramnios, first trimester, fetus 4 10/1/2015 12/31/2299 O401XX5 Polyhydramnios, first trimester, fetus 5 10/1/2015 12/31/2299 O401XX9 Polyhydramnios, first trimester, other fetus 10/1/2015 12/31/2299 O402XX0 Polyhydramnios, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O402XX1 Polyhydramnios, second trimester, fetus 1 10/1/2015 12/31/2299 O402XX2 Polyhydramnios, second trimester, fetus 2 10/1/2015 12/31/2299 O402XX3 Polyhydramnios, second trimester, fetus 3 10/1/2015 12/31/2299 O402XX4 Polyhydramnios, second trimester, fetus 4 10/1/2015 12/31/2299 O402XX5 Polyhydramnios, second trimester, fetus 5 10/1/2015 12/31/2299 O402XX9 Polyhydramnios, second trimester, other fetus 10/1/2015 12/31/2299 O403XX0 Polyhydramnios, third trimester, not applicable or unsp 10/1/2015 12/31/2299
228 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O403XX1 Polyhydramnios, third trimester, fetus 1 10/1/2015 12/31/2299 O403XX2 Polyhydramnios, third trimester, fetus 2 10/1/2015 12/31/2299 O403XX3 Polyhydramnios, third trimester, fetus 3 10/1/2015 12/31/2299 O403XX4 Polyhydramnios, third trimester, fetus 4 10/1/2015 12/31/2299 O403XX5 Polyhydramnios, third trimester, fetus 5 10/1/2015 12/31/2299 O403XX9 Polyhydramnios, third trimester, other fetus 10/1/2015 12/31/2299 O4101X0 Oligohydramnios, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O4101X1 Oligohydramnios, first trimester, fetus 1 10/1/2015 12/31/2299 O4101X2 Oligohydramnios, first trimester, fetus 2 10/1/2015 12/31/2299 O4101X3 Oligohydramnios, first trimester, fetus 3 10/1/2015 12/31/2299 O4101X4 Oligohydramnios, first trimester, fetus 4 10/1/2015 12/31/2299 O4101X5 Oligohydramnios, first trimester, fetus 5 10/1/2015 12/31/2299 O4101X9 Oligohydramnios, first trimester, other fetus 10/1/2015 12/31/2299 O4102X0 Oligohydramnios, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O4102X1 Oligohydramnios, second trimester, fetus 1 10/1/2015 12/31/2299 O4102X2 Oligohydramnios, second trimester, fetus 2 10/1/2015 12/31/2299 O4102X3 Oligohydramnios, second trimester, fetus 3 10/1/2015 12/31/2299 O4102X4 Oligohydramnios, second trimester, fetus 4 10/1/2015 12/31/2299 O4102X5 Oligohydramnios, second trimester, fetus 5 10/1/2015 12/31/2299 O4102X9 Oligohydramnios, second trimester, other fetus 10/1/2015 12/31/2299 O4103X0 Oligohydramnios, third trimester, not applicable or unsp 10/1/2015 12/31/2299 O4103X1 Oligohydramnios, third trimester, fetus 1 10/1/2015 12/31/2299 O4103X2 Oligohydramnios, third trimester, fetus 2 10/1/2015 12/31/2299 O4103X3 Oligohydramnios, third trimester, fetus 3 10/1/2015 12/31/2299 O4103X4 Oligohydramnios, third trimester, fetus 4 10/1/2015 12/31/2299 O4103X5 Oligohydramnios, third trimester, fetus 5 10/1/2015 12/31/2299 O4103X9 Oligohydramnios, third trimester, other fetus 10/1/2015 12/31/2299 O411010 Infct of amniotic sac and membrns, unsp, first tri, unsp 10/1/2015 12/31/2299 O411011 Infct of amniotic sac and membrns, unsp, first tri, fetus 1 10/1/2015 12/31/2299 O411012 Infct of amniotic sac and membrns, unsp, first tri, fetus 2 10/1/2015 12/31/2299 O411013 Infct of amniotic sac and membrns, unsp, first tri, fetus 3 10/1/2015 12/31/2299 O411014 Infct of amniotic sac and membrns, unsp, first tri, fetus 4 10/1/2015 12/31/2299
229 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O411015 Infct of amniotic sac and membrns, unsp, first tri, fetus 5 10/1/2015 12/31/2299 O411019 Infct of amniotic sac and membrns, unsp, first tri, oth 10/1/2015 12/31/2299 O411020 Infct of amniotic sac and membrns, unsp, second tri, unsp 10/1/2015 12/31/2299 O411021 Infct of amniotic sac and membrns, unsp, second tri, fetus 1 10/1/2015 12/31/2299 O411022 Infct of amniotic sac and membrns, unsp, second tri, fetus 2 10/1/2015 12/31/2299 O411023 Infct of amniotic sac and membrns, unsp, second tri, fetus 3 10/1/2015 12/31/2299 O411024 Infct of amniotic sac and membrns, unsp, second tri, fetus 4 10/1/2015 12/31/2299 O411025 Infct of amniotic sac and membrns, unsp, second tri, fetus 5 10/1/2015 12/31/2299 O411029 Infct of amniotic sac and membrns, unsp, second tri, oth 10/1/2015 12/31/2299 O411030 Infct of amniotic sac and membrns, unsp, third tri, unsp 10/1/2015 12/31/2299 O411031 Infct of amniotic sac and membrns, unsp, third tri, fetus 1 10/1/2015 12/31/2299 O411032 Infct of amniotic sac and membrns, unsp, third tri, fetus 2 10/1/2015 12/31/2299 O411033 Infct of amniotic sac and membrns, unsp, third tri, fetus 3 10/1/2015 12/31/2299 O411034 Infct of amniotic sac and membrns, unsp, third tri, fetus 4 10/1/2015 12/31/2299 O411035 Infct of amniotic sac and membrns, unsp, third tri, fetus 5 10/1/2015 12/31/2299 O411039 Infct of amniotic sac and membrns, unsp, third tri, oth 10/1/2015 12/31/2299 O411210 Chorioamnionitis, first trimester, not applicable or unsp 10/1/2015 12/31/2299 O411211 Chorioamnionitis, first trimester, fetus 1 10/1/2015 12/31/2299 O411212 Chorioamnionitis, first trimester, fetus 2 10/1/2015 12/31/2299 O411213 Chorioamnionitis, first trimester, fetus 3 10/1/2015 12/31/2299 O411214 Chorioamnionitis, first trimester, fetus 4 10/1/2015 12/31/2299 O411215 Chorioamnionitis, first trimester, fetus 5 10/1/2015 12/31/2299 O411219 Chorioamnionitis, first trimester, other fetus 10/1/2015 12/31/2299 O411220 Chorioamnionitis, second trimester, not applicable or unsp 10/1/2015 12/31/2299 O411221 Chorioamnionitis, second trimester, fetus 1 10/1/2015 12/31/2299 O411222 Chorioamnionitis, second trimester, fetus 2 10/1/2015 12/31/2299 O411223 Chorioamnionitis, second trimester, fetus 3 10/1/2015 12/31/2299 O411224 Chorioamnionitis, second trimester, fetus 4 10/1/2015 12/31/2299 O411225 Chorioamnionitis, second trimester, fetus 5 10/1/2015 12/31/2299 O411229 Chorioamnionitis, second trimester, other fetus 10/1/2015 12/31/2299 O411230 Chorioamnionitis, third trimester, not applicable or unsp 10/1/2015 12/31/2299 O411231 Chorioamnionitis, third trimester, fetus 1 10/1/2015 12/31/2299
230 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O411232 Chorioamnionitis, third trimester, fetus 2 10/1/2015 12/31/2299 O411233 Chorioamnionitis, third trimester, fetus 3 10/1/2015 12/31/2299 O411234 Chorioamnionitis, third trimester, fetus 4 10/1/2015 12/31/2299 O411235 Chorioamnionitis, third trimester, fetus 5 10/1/2015 12/31/2299 O411239 Chorioamnionitis, third trimester, other fetus 10/1/2015 12/31/2299 O411410 Placentitis, first trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411411 Placentitis, first trimester, fetus 1 10/1/2015 12/31/2299 O411412 Placentitis, first trimester, fetus 2 10/1/2015 12/31/2299 O411413 Placentitis, first trimester, fetus 3 10/1/2015 12/31/2299 O411414 Placentitis, first trimester, fetus 4 10/1/2015 12/31/2299 O411415 Placentitis, first trimester, fetus 5 10/1/2015 12/31/2299 O411419 Placentitis, first trimester, other fetus 10/1/2015 12/31/2299 O411420 Placentitis, second trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411421 Placentitis, second trimester, fetus 1 10/1/2015 12/31/2299 O411422 Placentitis, second trimester, fetus 2 10/1/2015 12/31/2299 O411423 Placentitis, second trimester, fetus 3 10/1/2015 12/31/2299 O411424 Placentitis, second trimester, fetus 4 10/1/2015 12/31/2299 O411425 Placentitis, second trimester, fetus 5 10/1/2015 12/31/2299 O411429 Placentitis, second trimester, other fetus 10/1/2015 12/31/2299 O411430 Placentitis, third trimester, not applicable or unspecified 10/1/2015 12/31/2299 O411431 Placentitis, third trimester, fetus 1 10/1/2015 12/31/2299 O411432 Placentitis, third trimester, fetus 2 10/1/2015 12/31/2299 O411433 Placentitis, third trimester, fetus 3 10/1/2015 12/31/2299 O411434 Placentitis, third trimester, fetus 4 10/1/2015 12/31/2299 O411435 Placentitis, third trimester, fetus 5 10/1/2015 12/31/2299 O411439 Placentitis, third trimester, other fetus 10/1/2015 12/31/2299 O418X10 Oth disrd of amniotic fluid and membrns, first tri, unsp 10/1/2015 12/31/2299 O418X11 Oth disrd of amniotic fluid and membrns, first tri, fetus 1 10/1/2015 12/31/2299 O418X12 Oth disrd of amniotic fluid and membrns, first tri, fetus 2 10/1/2015 12/31/2299 O418X13 Oth disrd of amniotic fluid and membrns, first tri, fetus 3 10/1/2015 12/31/2299 O418X14 Oth disrd of amniotic fluid and membrns, first tri, fetus 4 10/1/2015 12/31/2299 O418X15 Oth disrd of amniotic fluid and membrns, first tri, fetus 5 10/1/2015 12/31/2299
231 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O418X19 Oth disrd of amniotic fluid and membrns, first tri, oth 10/1/2015 12/31/2299 O418X20 Oth disrd of amniotic fluid and membrns, second tri, unsp 10/1/2015 12/31/2299 O418X21 Oth disrd of amniotic fluid and membrns, second tri, fetus 1 10/1/2015 12/31/2299 O418X22 Oth disrd of amniotic fluid and membrns, second tri, fetus 2 10/1/2015 12/31/2299 O418X23 Oth disrd of amniotic fluid and membrns, second tri, fetus 3 10/1/2015 12/31/2299 O418X24 Oth disrd of amniotic fluid and membrns, second tri, fetus 4 10/1/2015 12/31/2299 O418X25 Oth disrd of amniotic fluid and membrns, second tri, fetus 5 10/1/2015 12/31/2299 O418X29 Oth disrd of amniotic fluid and membrns, second tri, oth 10/1/2015 12/31/2299 O418X30 Oth disrd of amniotic fluid and membrns, third tri, unsp 10/1/2015 12/31/2299 O418X31 Oth disrd of amniotic fluid and membrns, third tri, fetus 1 10/1/2015 12/31/2299 O418X32 Oth disrd of amniotic fluid and membrns, third tri, fetus 2 10/1/2015 12/31/2299 O418X33 Oth disrd of amniotic fluid and membrns, third tri, fetus 3 10/1/2015 12/31/2299 O418X34 Oth disrd of amniotic fluid and membrns, third tri, fetus 4 10/1/2015 12/31/2299 O418X35 Oth disrd of amniotic fluid and membrns, third tri, fetus 5 10/1/2015 12/31/2299 O418X39 Oth disrd of amniotic fluid and membrns, third tri, oth 10/1/2015 12/31/2299 O42011 Pretrm prem ROM, onset labor w/n 24 hours of rupt, first tri 10/1/2015 12/31/2299 O42012 Pretrm prem ROM, onset labor w/n 24 hours of rupt, 2nd tri 10/1/2015 12/31/2299 O42013 Pretrm prem ROM, onset labor w/n 24 hours of rupt, third tri 10/1/2015 12/31/2299 O42111 Pretrm prem ROM, onset labor > 24 hours fol rupt, first tri 10/1/2015 12/31/2299 O42112 Pretrm prem ROM, onset labor > 24 hours fol rupt, second tri 10/1/2015 12/31/2299 O42113 Pretrm prem ROM, onset labor > 24 hours fol rupt, third tri 10/1/2015 12/31/2299 O42911 Pretrm prem ROM, unsp time betw rupt and onset labr, 1st tri 10/1/2015 12/31/2299 O42912 Pretrm prem ROM, unsp time betw rupt and onset labr, 2nd tri 10/1/2015 12/31/2299 O42913 Pretrm prem ROM, unsp time betw rupt and onst labr, 3rd tri 10/1/2015 12/31/2299 O43011 Fetomaternal placental transfusion syndrome, first trimester 10/1/2015 12/31/2299 O43012 Fetomaternal placental transfuse syndrome, second trimester 10/1/2015 12/31/2299 O43013 Fetomaternal placental transfusion syndrome, third trimester 10/1/2015 12/31/2299 O43021 Fetus-to-fetus placental transfuse syndrome, first trimester 10/1/2015 12/31/2299 O43022 Fetus-to-fetus placntl transfuse syndrome, second trimester 10/1/2015 12/31/2299 O43023 Fetus-to-fetus placental transfuse syndrome, third trimester 10/1/2015 12/31/2299 O43101 Malformation of placenta, unspecified, first trimester 10/1/2015 12/31/2299 O43102 Malformation of placenta, unspecified, second trimester 10/1/2015 12/31/2299
232 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O43103 Malformation of placenta, unspecified, third trimester 10/1/2015 12/31/2299 O43111 Circumvallate placenta, first trimester 10/1/2015 12/31/2299 O43112 Circumvallate placenta, second trimester 10/1/2015 12/31/2299 O43113 Circumvallate placenta, third trimester 10/1/2015 12/31/2299 O43191 Other malformation of placenta, first trimester 10/1/2015 12/31/2299 O43192 Other malformation of placenta, second trimester 10/1/2015 12/31/2299 O43193 Other malformation of placenta, third trimester 10/1/2015 12/31/2299 O43811 Placental infarction, first trimester 10/1/2015 12/31/2299 O43812 Placental infarction, second trimester 10/1/2015 12/31/2299 O43813 Placental infarction, third trimester 10/1/2015 12/31/2299 O43891 Other placental disorders, first trimester 10/1/2015 12/31/2299 O43892 Other placental disorders, second trimester 10/1/2015 12/31/2299 O43893 Other placental disorders, third trimester 10/1/2015 12/31/2299 O4391 Unspecified placental disorder, first trimester 10/1/2015 12/31/2299 O4392 Unspecified placental disorder, second trimester 10/1/2015 12/31/2299 O4393 Unspecified placental disorder, third trimester 10/1/2015 12/31/2299 O4401 Complete placenta previa NOS or without hemor, first tri 10/1/2015 12/31/2299 O4402 Complete placenta previa NOS or without hemor, second tri 10/1/2015 12/31/2299 O4403 Complete placenta previa NOS or without hemor, third tri 10/1/2015 12/31/2299 O4411 Complete placenta previa with hemorrhage, first trimester 10/1/2015 12/31/2299 O4412 Complete placenta previa with hemorrhage, second trimester 10/1/2015 12/31/2299 O4413 Complete placenta previa with hemorrhage, third trimester 10/1/2015 12/31/2299 O4421 Partial placenta previa NOS or without hemor, first tri 10/1/2016 12/31/2299 O4422 Partial placenta previa NOS or without hemor, second tri 10/1/2016 12/31/2299 O4423 Partial placenta previa NOS or without hemor, third tri 10/1/2016 12/31/2299 O4431 Partial placenta previa with hemorrhage, first trimester 10/1/2016 12/31/2299 O4432 Partial placenta previa with hemorrhage, second trimester 10/1/2016 12/31/2299 O4433 Partial placenta previa with hemorrhage, third trimester 10/1/2016 12/31/2299 O4441 Low lying placenta NOS or without hemor, first trimester 10/1/2016 12/31/2299 O4442 Low lying placenta NOS or without hemor, second trimester 10/1/2016 12/31/2299 O4443 Low lying placenta NOS or without hemor, third trimester 10/1/2016 12/31/2299 O4451 Low lying placenta with hemorrhage, first trimester 10/1/2016 12/31/2299
233 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O4452 Low lying placenta with hemorrhage, second trimester 10/1/2016 12/31/2299 O4453 Low lying placenta with hemorrhage, third trimester 10/1/2016 12/31/2299 O45011 Prem separtn of placenta w afibrinogenemia, first trimester 10/1/2015 12/31/2299 O45012 Prem separtn of placenta w afibrinogenemia, second trimester 10/1/2015 12/31/2299 O45013 Prem separtn of placenta w afibrinogenemia, third trimester 10/1/2015 12/31/2299 O45021 Prem separtn of placenta w dissem intravasc coag, first tri 10/1/2015 12/31/2299 O45022 Prem separtn of placenta w dissem intravasc coag, second tri 10/1/2015 12/31/2299 O45023 Prem separtn of placenta w dissem intravasc coag, third tri 10/1/2015 12/31/2299 O45091 Prem separtn of placenta w oth coag defect, first trimester 10/1/2015 12/31/2299 O45092 Prem separtn of placenta w oth coag defect, second trimester 10/1/2015 12/31/2299 O45093 Prem separtn of placenta w oth coag defect, third trimester 10/1/2015 12/31/2299 O458X1 Other premature separation of placenta, first trimester 10/1/2015 12/31/2299 O458X2 Other premature separation of placenta, second trimester 10/1/2015 12/31/2299 O458X3 Other premature separation of placenta, third trimester 10/1/2015 12/31/2299 O46011 Antepartum hemorrhage with afibrinogenemia, first trimester 10/1/2015 12/31/2299 O46012 Antepartum hemorrhage with afibrinogenemia, second trimester 10/1/2015 12/31/2299 O46013 Antepartum hemorrhage with afibrinogenemia, third trimester 10/1/2015 12/31/2299 O46021 Antepart hemorrhage w dissem intravasc coag, first trimester 10/1/2015 12/31/2299 O46022 Antepart hemor w dissem intravasc coag, second trimester 10/1/2015 12/31/2299 O46023 Antepart hemorrhage w dissem intravasc coag, third trimester 10/1/2015 12/31/2299 O46091 Antepartum hemorrhage w oth coag defect, first trimester 10/1/2015 12/31/2299 O46092 Antepartum hemorrhage w oth coag defect, second trimester 10/1/2015 12/31/2299 O46093 Antepartum hemorrhage w oth coag defect, third trimester 10/1/2015 12/31/2299 O4702 False labor before 37 completed weeks of gest, second tri 10/1/2015 12/31/2299 O4703 False labor before 37 completed weeks of gest, third tri 10/1/2015 12/31/2299 O471 False labor at or after 37 completed weeks of gestation 10/1/2015 12/31/2299 O480 Post-term pregnancy 10/1/2015 12/31/2299 O481 Prolonged pregnancy 10/1/2015 12/31/2299 O6002 Preterm labor without delivery, second trimester 10/1/2015 12/31/2299 O6003 Preterm labor without delivery, third trimester 10/1/2015 12/31/2299 O610 Failed medical induction of labor 10/1/2015 12/31/2299 O611 Failed instrumental induction of labor 10/1/2015 12/31/2299
234 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O620 Primary inadequate contractions 10/1/2015 12/31/2299 O621 Secondary uterine inertia 10/1/2015 12/31/2299 O622 Other uterine inertia 10/1/2015 12/31/2299 O623 Precipitate labor 10/1/2015 12/31/2299 O624 Hypertonic, incoordinate, and prolonged uterine contractions 10/1/2015 12/31/2299 O630 Prolonged first stage (of labor) 10/1/2015 12/31/2299 O631 Prolonged second stage (of labor) 10/1/2015 12/31/2299 O632 Delayed delivery of second twin, triplet, etc. 10/1/2015 12/31/2299 O640XX0 Obstructed labor due to incmpl rotation of fetal head, unsp 10/1/2015 12/31/2299 O649XX0 Obstructed labor due to malpos and malpresent, unsp, unsp 10/1/2015 12/31/2299 O654 Obstructed labor due to fetopelvic disproportion, unsp 10/1/2015 12/31/2299 O659 Obstructed labor due to maternal pelvic abnormality, unsp 10/1/2015 12/31/2299 O660 Obstructed labor due to shoulder dystocia 10/1/2015 12/31/2299 O661 Obstructed labor due to locked twins 10/1/2015 12/31/2299 O6640 Failed trial of labor, unspecified 10/1/2015 12/31/2299 O665 Attempted application of vacuum extractor and forceps 10/1/2015 12/31/2299 O668 Other specified obstructed labor 10/1/2015 12/31/2299 O68 Labor and delivery comp by abnlt of fetal acid-base balance 10/1/2015 12/31/2299 O690XX0 Labor and delivery complicated by prolapse of cord, unsp 10/1/2015 12/31/2299 O691XX0 Labor and delivery comp by cord around neck, w comprsn, unsp 10/1/2015 12/31/2299 O692XX0 Labor and del comp by oth cord entangle, w comprsn, unsp 10/1/2015 12/31/2299 O693XX0 Labor and delivery complicated by short cord, unsp 10/1/2015 12/31/2299 O694XX0 Labor and delivery complicated by vasa previa, unsp 10/1/2015 12/31/2299 O695XX0 Labor and delivery comp by vascular lesion of cord, unsp 10/1/2015 12/31/2299 O6989X0 Labor and delivery complicated by oth cord comp, unsp 10/1/2015 12/31/2299 O752 Pyrexia during labor, not elsewhere classified 10/1/2015 12/31/2299 O753 Other infection during labor 10/1/2015 12/31/2299 O755 Delayed delivery after artificial rupture of membranes 10/1/2015 12/31/2299 O7589 Other specified complications of labor and delivery 10/1/2015 12/31/2299 O76 Abnlt in fetal heart rate and rhythm comp labor and delivery 10/1/2015 12/31/2299 O88011 Air embolism in pregnancy, first trimester 10/1/2015 12/31/2299 O88012 Air embolism in pregnancy, second trimester 10/1/2015 12/31/2299
235 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O88013 Air embolism in pregnancy, third trimester 10/1/2015 12/31/2299 O88111 Amniotic fluid embolism in pregnancy, first trimester 10/1/2015 12/31/2299 O88112 Amniotic fluid embolism in pregnancy, second trimester 10/1/2015 12/31/2299 O88113 Amniotic fluid embolism in pregnancy, third trimester 10/1/2015 12/31/2299 O88211 Thromboembolism in pregnancy, first trimester 10/1/2015 12/31/2299 O88212 Thromboembolism in pregnancy, second trimester 10/1/2015 12/31/2299 O88213 Thromboembolism in pregnancy, third trimester 10/1/2015 12/31/2299 O88311 Pyemic and septic embolism in pregnancy, first trimester 10/1/2015 12/31/2299 O88312 Pyemic and septic embolism in pregnancy, second trimester 10/1/2015 12/31/2299 O88313 Pyemic and septic embolism in pregnancy, third trimester 10/1/2015 12/31/2299 O98011 Tuberculosis complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98012 Tuberculosis complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98013 Tuberculosis complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98111 Syphilis complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98112 Syphilis complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98113 Syphilis complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98211 Gonorrhea complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98212 Gonorrhea complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98213 Gonorrhea complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98311 Oth infect w sexl mode of transmiss comp preg, first tri 10/1/2015 12/31/2299 O98312 Oth infect w sexl mode of transmiss comp preg, second tri 10/1/2015 12/31/2299 O98313 Oth infect w sexl mode of transmiss comp preg, third tri 10/1/2015 12/31/2299 O98411 Viral hepatitis complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98412 Viral hepatitis complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98413 Viral hepatitis complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98511 Other viral diseases complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98512 Oth viral diseases complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98513 Other viral diseases complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98611 Protozoal diseases complicating pregnancy, first trimester 10/1/2015 12/31/2299 O98612 Protozoal diseases complicating pregnancy, second trimester 10/1/2015 12/31/2299 O98613 Protozoal diseases complicating pregnancy, third trimester 10/1/2015 12/31/2299 O98711 Human immunodef virus disease comp preg, first trimester 10/1/2015 12/31/2299
236 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O98712 Human immunodef virus disease comp preg, second trimester 10/1/2015 12/31/2299 O98713 Human immunodef virus disease comp preg, third trimester 10/1/2015 12/31/2299 O99011 Anemia complicating pregnancy, first trimester 10/1/2015 12/31/2299 O99012 Anemia complicating pregnancy, second trimester 10/1/2015 12/31/2299 O99013 Anemia complicating pregnancy, third trimester 10/1/2015 12/31/2299 O99111 Oth dis of bld/bld-form org/immun mechnsm comp preg, 1st tri 10/1/2015 12/31/2299 O99112 Oth dis of bld/bld-form org/immun mechnsm comp preg, 2nd tri 10/1/2015 12/31/2299 O99113 Oth dis of bld/bld-form org/immun mechnsm comp preg, 3rd tri 10/1/2015 12/31/2299 O99211 Obesity complicating pregnancy, first trimester 10/1/2015 12/31/2299 O99212 Obesity complicating pregnancy, second trimester 10/1/2015 12/31/2299 O99213 Obesity complicating pregnancy, third trimester 10/1/2015 12/31/2299 O99281 Endo, nutritional and metab diseases comp preg, first tri 10/1/2015 12/31/2299 O99282 Endo, nutritional and metab diseases comp preg, second tri 10/1/2015 12/31/2299 O99283 Endo, nutritional and metab diseases comp preg, third tri 10/1/2015 12/31/2299 O99311 Alcohol use complicating pregnancy, first trimester 10/1/2015 12/31/2299 O99312 Alcohol use complicating pregnancy, second trimester 10/1/2015 12/31/2299 O99313 Alcohol use complicating pregnancy, third trimester 10/1/2015 12/31/2299 O99321 Drug use complicating pregnancy, first trimester 10/1/2015 12/31/2299 O99322 Drug use complicating pregnancy, second trimester 10/1/2015 12/31/2299 O99323 Drug use complicating pregnancy, third trimester 10/1/2015 12/31/2299 O99331 Smoking (tobacco) complicating pregnancy, first trimester 10/1/2015 12/31/2299 O99332 Smoking (tobacco) complicating pregnancy, second trimester 10/1/2015 12/31/2299 O99333 Smoking (tobacco) complicating pregnancy, third trimester 10/1/2015 12/31/2299 O99351 Diseases of the nervous sys comp pregnancy, first trimester 10/1/2015 12/31/2299 O99352 Diseases of the nervous sys comp pregnancy, second trimester 10/1/2015 12/31/2299 O99353 Diseases of the nervous sys comp pregnancy, third trimester 10/1/2015 12/31/2299 O99411 Diseases of the circ sys comp pregnancy, first trimester 10/1/2015 12/31/2299 O99412 Diseases of the circ sys comp pregnancy, second trimester 10/1/2015 12/31/2299 O99413 Diseases of the circ sys comp pregnancy, third trimester 10/1/2015 12/31/2299 O99810 Abnormal glucose complicating pregnancy 10/1/2015 12/31/2299 O99841 Bariatric surgery status comp pregnancy, first trimester 10/1/2015 12/31/2299 O99842 Bariatric surgery status comp pregnancy, second trimester 10/1/2015 12/31/2299
237 Table 13b Diagnosis Codes for High Risk Obstetrical Radiology Services Use ICD- ICD-10-CM descriptions Effective End Date 10-CM Date codes O99843 Bariatric surgery status comp pregnancy, third trimester 10/1/2015 12/31/2299 Z0371 Encntr for susp prob w amnio cavity and membrane ruled out 10/1/2015 12/31/2299 Z0372 Encounter for suspected placental problem ruled out 10/1/2015 12/31/2299 Z0373 Encounter for suspected fetal anomaly ruled out 10/1/2015 12/31/2299 Z0374 Encounter for suspected problem with fetal growth ruled out 10/1/2015 12/31/2299 Z0375 Encounter for suspected cervical shortening ruled out 10/1/2015 12/31/2299 Z0379 Encntr for oth suspected maternal and fetal cond ruled out 10/1/2015 12/31/2299 Z369 Encounter for antenatal screening unspecified 10/1/2017 12/31/2299
Table Listing, Previous Table 13b, Next Table 15, End of Document
Table 14: Kessner Index for Insufficient Prenatal Care
Table 14 Kessner Index For Insufficient Prenatal Care
Gestation (weeks)**** ADEQUATE* Number of Prenatal Visits 13 or less AND 1 or more or not stated 14-17 AND 2 or more 18-21 AND 3 or more 22-25 AND 4 or more 26-29 AND 5 or more 30-31 AND 6 or more 32-33 AND 7 or more 34-35 AND 8 or more 36 or more AND 9 or more
Table 14 Kessner Index For Insufficient Prenatal Care
Gestation (weeks)**** INADEQUATE** Number of Prenatal Visits 14-21*** AND 0 or not stated 22-29 AND 1 or less or not stated
238 Table 14 Kessner Index For Insufficient Prenatal Care
Gestation (weeks)**** INADEQUATE** Number of Prenatal Visits 30-31 AND 2 or less or not stated 32-33 AND 3 or less or not stated 34 or more AND 4 or less or not stated
INTERMEDIATE: All combinations other than specified above * In addition to the specified number of visits indicated for adequate care, the Interval to the first prenatal visit has to be 13 weeks or less (first trimester). ** In addition to the specified number of visits indicated for inadequate care, all Women who started their prenatal care during the third trimester (28 weeks or later) are considered inadequate. *** For this gestation group, care is considered inadequate if the time of the first visit is not stated. **** When month and year are specified but day is missing, input 15 for day. Adequacy categories are in accord with recommendations of American College of Obstetrics and Gynecology and the World Health Organization.
Source: Institute of Medicine, National Academy of Sciences: Infant Deaths, An Analysis by Maternal Risk and Health Care. In: Contrasts in Health Status, Vol. I, 1973. Based on: The American College of Obstetricians and Gynecologists: Standards for Obstetric-Gynecologic Services. Chicago, 1974. Internal modifications have been made to differentiate those having "no care" from those having "inadequate" or "intermediate care."
Table Listing, Previous Table 14, Next Table 16, End of Document
Table 15: All Physical Therapy, Occupational Therapy and Speech Pathology Treatment Services in excess of nine treatments per calendar year per provider per client, involving the following primary diagnoses:
Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F0281 Dementia in oth diseases classd elswhr w behavioral disturb 20151001 22991231
239 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F0391 Unspecified dementia with behavioral disturbance 20151001 22991231 F060 Psychotic disorder w hallucin due to known physiol condition 20151001 22991231 F061 Catatonic disorder due to known physiological condition 20151001 22991231 F062 Psychotic disorder w delusions due to known physiol cond 20151001 22991231 F0630 Mood disorder due to known physiological condition, unsp 20151001 22991231 F0631 Mood disorder due to known physiol cond w depressv features 20151001 22991231 F0632 Mood disord d/t physiol cond w major depressive-like epsd 20151001 22991231 F0633 Mood disorder due to known physiol cond w manic features 20151001 22991231 F0634 Mood disorder due to known physiol cond w mixed features 20151001 22991231 F064 Anxiety disorder due to known physiological condition 20151001 22991231 F070 Personality change due to known physiological condition 20151001 22991231 F0789 Oth personality & behavrl disord due to known physiol cond 20151001 22991231 F1010 Alcohol abuse, uncomplicated 20151001 22991231 F10120 Alcohol abuse with intoxication, uncomplicated 20151001 22991231 F10121 Alcohol abuse with intoxication delirium 20151001 22991231 F10129 Alcohol abuse with intoxication, unspecified 20151001 22991231 F10130 Alcohol abuse with withdrawal, uncomplicated 20201001 22991231 F10131 Alcohol abuse with withdrawal delirium 20201001 22991231 F10132 Alcohol abuse with withdrawal with perceptual disturbance 20201001 22991231 F10139 Alcohol abuse with withdrawal, unspecified 20201001 22991231 F1014 Alcohol abuse with alcohol-induced mood disorder 20151001 22991231 F10150 Alcohol abuse w alcoh-induce psychotic disorder w delusions 20151001 22991231 F10151 Alcohol abuse w alcoh-induce psychotic disorder w hallucin 20151001 22991231 F10159 Alcohol abuse with alcohol-induced psychotic disorder, unsp 20151001 22991231 F10180 Alcohol abuse with alcohol-induced anxiety disorder 20151001 22991231 F10181 Alcohol abuse with alcohol-induced sexual dysfunction 20151001 22991231 F10182 Alcohol abuse with alcohol-induced sleep disorder 20151001 22991231 F10188 Alcohol abuse with other alcohol-induced disorder 20151001 22991231 F1019 Alcohol abuse with unspecified alcohol-induced disorder 20151001 22991231 F1020 Alcohol dependence, uncomplicated 20151001 22991231 F1021 Alcohol dependence, in remission 20151001 22991231
240 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F10220 Alcohol dependence with intoxication, uncomplicated 20151001 22991231 F10221 Alcohol dependence with intoxication delirium 20151001 22991231 F10229 Alcohol dependence with intoxication, unspecified 20151001 22991231 F10230 Alcohol dependence with withdrawal, uncomplicated 20151001 22991231 F10231 Alcohol dependence with withdrawal delirium 20151001 22991231 F10232 Alcohol dependence w withdrawal with perceptual disturbance 20151001 22991231 F10239 Alcohol dependence with withdrawal, unspecified 20151001 22991231 F1024 Alcohol dependence with alcohol-induced mood disorder 20151001 22991231 F10250 Alcohol depend w alcoh-induce psychotic disorder w delusions 20151001 22991231 F10251 Alcohol depend w alcoh-induce psychotic disorder w hallucin 20151001 22991231 F10259 Alcohol dependence w alcoh-induce psychotic disorder, unsp 20151001 22991231 F1026 Alcohol depend w alcoh-induce persisting amnestic disorder 20151001 22991231 F1027 Alcohol dependence with alcohol-induced persisting dementia 20151001 22991231 F10280 Alcohol dependence with alcohol-induced anxiety disorder 20151001 22991231 F10281 Alcohol dependence with alcohol-induced sexual dysfunction 20151001 22991231 F10282 Alcohol dependence with alcohol-induced sleep disorder 20151001 22991231 F10288 Alcohol dependence with other alcohol-induced disorder 20151001 22991231 F1029 Alcohol dependence with unspecified alcohol-induced disorder 20151001 22991231 F10920 Alcohol use, unspecified with intoxication, uncomplicated 20151001 22991231 F10921 Alcohol use, unspecified with intoxication delirium 20151001 22991231 F10929 Alcohol use, unspecified with intoxication, unspecified 20151001 22991231 F10930 Alcohol use, unspecified with withdrawal, uncomplicated 20201001 22991231 F10931 Alcohol use, unspecified with withdrawal delirium 20201001 22991231 F10932 Alcohol use, unspecified with w/drawal w perceptual disturb 20201001 22991231 F10939 Alcohol use, unspecified with withdrawal, unspecified 20201001 22991231 F1094 Alcohol use, unspecified with alcohol-induced mood disorder 20151001 22991231 F10950 Alcohol use, unsp w alcoh-induce psych disorder w delusions 20151001 22991231 F10951 Alcohol use, unsp w alcoh-induce psych disorder w hallucin 20151001 22991231 F10959 Alcohol use, unsp w alcohol-induced psychotic disorder, unsp 20151001 22991231 F1096 Alcohol use, unsp w alcoh-induce persist amnestic disorder 20151001 22991231 F1097 Alcohol use, unsp with alcohol-induced persisting dementia 20151001 22991231
241 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F10980 Alcohol use, unsp with alcohol-induced anxiety disorder 20151001 22991231 F10981 Alcohol use, unsp with alcohol-induced sexual dysfunction 20151001 22991231 F10982 Alcohol use, unspecified with alcohol-induced sleep disorder 20151001 22991231 F10988 Alcohol use, unspecified with other alcohol-induced disorder 20151001 22991231 F1099 Alcohol use, unsp with unspecified alcohol-induced disorder 20151001 22991231 F1110 Opioid abuse, uncomplicated 20151001 22991231 F11120 Opioid abuse with intoxication, uncomplicated 20151001 22991231 F11121 Opioid abuse with intoxication delirium 20151001 22991231 F11122 Opioid abuse with intoxication with perceptual disturbance 20151001 22991231 F11129 Opioid abuse with intoxication, unspecified 20151001 22991231 F1113 Opioid abuse with withdrawal 20201001 22991231 F1114 Opioid abuse with opioid-induced mood disorder 20151001 22991231 F11150 Opioid abuse w opioid-induced psychotic disorder w delusions 20151001 22991231 F11151 Opioid abuse w opioid-induced psychotic disorder w hallucin 20151001 22991231 F11159 Opioid abuse with opioid-induced psychotic disorder, unsp 20151001 22991231 F11181 Opioid abuse with opioid-induced sexual dysfunction 20151001 22991231 F11182 Opioid abuse with opioid-induced sleep disorder 20151001 22991231 F11188 Opioid abuse with other opioid-induced disorder 20151001 22991231 F1119 Opioid abuse with unspecified opioid-induced disorder 20151001 22991231 F1120 Opioid dependence, uncomplicated 20151001 22991231 F1121 Opioid dependence, in remission 20151001 22991231 F11220 Opioid dependence with intoxication, uncomplicated 20151001 22991231 F11221 Opioid dependence with intoxication delirium 20151001 22991231 F11222 Opioid dependence w intoxication with perceptual disturbance 20151001 22991231 F11229 Opioid dependence with intoxication, unspecified 20151001 22991231 F1123 Opioid dependence with withdrawal 20151001 22991231 F1124 Opioid dependence with opioid-induced mood disorder 20151001 22991231 F11250 Opioid depend w opioid-induc psychotic disorder w delusions 20151001 22991231 F11251 Opioid depend w opioid-induc psychotic disorder w hallucin 20151001 22991231 F11259 Opioid dependence w opioid-induced psychotic disorder, unsp 20151001 22991231 F11281 Opioid dependence with opioid-induced sexual dysfunction 20151001 22991231
242 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F11282 Opioid dependence with opioid-induced sleep disorder 20151001 22991231 F11288 Opioid dependence with other opioid-induced disorder 20151001 22991231 F1129 Opioid dependence with unspecified opioid-induced disorder 20151001 22991231 F1190 Opioid use, unspecified, uncomplicated 20151001 22991231 F11920 Opioid use, unspecified with intoxication, uncomplicated 20151001 22991231 F11921 Opioid use, unspecified with intoxication delirium 20151001 22991231 F11922 Opioid use, unsp w intoxication with perceptual disturbance 20151001 22991231 F11929 Opioid use, unspecified with intoxication, unspecified 20151001 22991231 F1193 Opioid use, unspecified with withdrawal 20151001 22991231 F1194 Opioid use, unspecified with opioid-induced mood disorder 20151001 22991231 F11950 Opioid use, unsp w opioid-induc psych disorder w delusions 20151001 22991231 F11951 Opioid use, unsp w opioid-induc psych disorder w hallucin 20151001 22991231 F11959 Opioid use, unsp w opioid-induced psychotic disorder, unsp 20151001 22991231 F11981 Opioid use, unsp with opioid-induced sexual dysfunction 20151001 22991231 F11982 Opioid use, unspecified with opioid-induced sleep disorder 20151001 22991231 F11988 Opioid use, unspecified with other opioid-induced disorder 20151001 22991231 F1199 Opioid use, unsp with unspecified opioid-induced disorder 20151001 22991231 F1210 Cannabis abuse, uncomplicated 20151001 22991231 F12120 Cannabis abuse with intoxication, uncomplicated 20151001 22991231 F12121 Cannabis abuse with intoxication delirium 20151001 22991231 F12122 Cannabis abuse with intoxication with perceptual disturbance 20151001 22991231 F12129 Cannabis abuse with intoxication, unspecified 20151001 22991231 F1213 Cannabis abuse with withdrawal 20201001 22991231 F12150 Cannabis abuse with psychotic disorder with delusions 20151001 22991231 F12151 Cannabis abuse with psychotic disorder with hallucinations 20151001 22991231 F12159 Cannabis abuse with psychotic disorder, unspecified 20151001 22991231 F12180 Cannabis abuse with cannabis-induced anxiety disorder 20151001 22991231 F12188 Cannabis abuse with other cannabis-induced disorder 20151001 22991231 F1219 Cannabis abuse with unspecified cannabis-induced disorder 20151001 22991231 F1220 Cannabis dependence, uncomplicated 20151001 22991231 F1221 Cannabis dependence, in remission 20151001 22991231
243 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F12220 Cannabis dependence with intoxication, uncomplicated 20151001 22991231 F12221 Cannabis dependence with intoxication delirium 20151001 22991231 F12222 Cannabis dependence w intoxication w perceptual disturbance 20151001 22991231 F12229 Cannabis dependence with intoxication, unspecified 20151001 22991231 F1223 Cannabis dependence with withdrawal 20181001 22991231 F12250 Cannabis dependence with psychotic disorder with delusions 20151001 22991231 F12251 Cannabis dependence w psychotic disorder with hallucinations 20151001 22991231 F12259 Cannabis dependence with psychotic disorder, unspecified 20151001 22991231 F12280 Cannabis dependence with cannabis-induced anxiety disorder 20151001 22991231 F12288 Cannabis dependence with other cannabis-induced disorder 20151001 22991231 F1229 Cannabis dependence with unsp cannabis-induced disorder 20151001 22991231 F1290 Cannabis use, unspecified, uncomplicated 20151001 22991231 F12920 Cannabis use, unspecified with intoxication, uncomplicated 20151001 22991231 F12921 Cannabis use, unspecified with intoxication delirium 20151001 22991231 F12922 Cannabis use, unsp w intoxication w perceptual disturbance 20151001 22991231 F12929 Cannabis use, unspecified with intoxication, unspecified 20151001 22991231 F1293 Cannabis use, unspecified with withdrawal 20181001 22991231 F12950 Cannabis use, unsp with psychotic disorder with delusions 20151001 22991231 F12951 Cannabis use, unsp w psychotic disorder with hallucinations 20151001 22991231 F12959 Cannabis use, unsp with psychotic disorder, unspecified 20151001 22991231 F12980 Cannabis use, unspecified with anxiety disorder 20151001 22991231 F12988 Cannabis use, unsp with other cannabis-induced disorder 20151001 22991231 F1299 Cannabis use, unsp with unsp cannabis-induced disorder 20151001 22991231 F1310 Sedative, hypnotic or anxiolytic abuse, uncomplicated 20151001 22991231 F13120 Sedatv/hyp/anxiolytc abuse w intoxication, uncomplicated 20151001 22991231 F13121 Sedatv/hyp/anxiolytc abuse w intoxication delirium 20151001 22991231 F13129 Sedative, hypnotic or anxiolytic abuse w intoxication, unsp 20151001 22991231 F13130 Sedatv/hyp/anxiolytc abuse with withdrawal, uncomplicated 20201001 22991231 F13131 Sedatv/hyp/anxiolytc abuse with withdrawal delirium 20201001 22991231 F13132 Sedatv/hyp/anxiolytc abuse with w/drawal w perceptl disturb 20201001 22991231 F13139 Sedatv/hyp/anxiolytc abuse with withdrawal, unspecified 20201001 22991231
244 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1314 Sedative, hypnotic or anxiolytic abuse w mood disorder 20151001 22991231 F13150 Sedatv/hyp/anxiolytc abuse w psychotic disorder w delusions 20151001 22991231 F13151 Sedatv/hyp/anxiolytc abuse w psychotic disorder w hallucin 20151001 22991231 F13159 Sedatv/hyp/anxiolytc abuse w psychotic disorder, unsp 20151001 22991231 F13180 Sedative, hypnotic or anxiolytic abuse w anxiety disorder 20151001 22991231 F13181 Sedative, hypnotic or anxiolytic abuse w sexual dysfunction 20151001 22991231 F13182 Sedative, hypnotic or anxiolytic abuse w sleep disorder 20151001 22991231 F13188 Sedative, hypnotic or anxiolytic abuse w oth disorder 20151001 22991231 F1319 Sedative, hypnotic or anxiolytic abuse w unsp disorder 20151001 22991231 F1320 Sedative, hypnotic or anxiolytic dependence, uncomplicated 20151001 22991231 F1321 Sedative, hypnotic or anxiolytic dependence, in remission 20151001 22991231 F13220 Sedatv/hyp/anxiolytc dependence w intoxication, uncomp 20151001 22991231 F13221 Sedatv/hyp/anxiolytc dependence w intoxication delirium 20151001 22991231 F13229 Sedatv/hyp/anxiolytc dependence w intoxication, unsp 20151001 22991231 F13230 Sedatv/hyp/anxiolytc dependence w withdrawal, uncomplicated 20151001 22991231 F13231 Sedatv/hyp/anxiolytc dependence w withdrawal delirium 20151001 22991231 F13232 Sedatv/hyp/anxiolytc depend w w/drawal w perceptual disturb 20151001 22991231 F13239 Sedatv/hyp/anxiolytc dependence w withdrawal, unsp 20151001 22991231 F1324 Sedative, hypnotic or anxiolytic dependence w mood disorder 20151001 22991231 F13250 Sedatv/hyp/anxiolytc depend w psychotic disorder w delusions 20151001 22991231 F13251 Sedatv/hyp/anxiolytc depend w psychotic disorder w hallucin 20151001 22991231 F13259 Sedatv/hyp/anxiolytc dependence w psychotic disorder, unsp 20151001 22991231 F1326 Sedatv/hyp/anxiolytc depend w persisting amnestic disorder 20151001 22991231 F1327 Sedatv/hyp/anxiolytc dependence w persisting dementia 20151001 22991231 F13280 Sedatv/hyp/anxiolytc dependence w anxiety disorder 20151001 22991231 F13281 Sedatv/hyp/anxiolytc dependence w sexual dysfunction 20151001 22991231 F13282 Sedative, hypnotic or anxiolytic dependence w sleep disorder 20151001 22991231 F13288 Sedative, hypnotic or anxiolytic dependence w oth disorder 20151001 22991231 F1329 Sedative, hypnotic or anxiolytic dependence w unsp disorder 20151001 22991231 F1390 Sedative, hypnotic, or anxiolytic use, unsp, uncomplicated 20151001 22991231 F13920 Sedatv/hyp/anxiolytc use, unsp w intoxication, uncomplicated 20151001 22991231
245 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F13921 Sedatv/hyp/anxiolytc use, unsp w intoxication delirium 20151001 22991231 F13929 Sedatv/hyp/anxiolytc use, unsp w intoxication, unsp 20151001 22991231 F13930 Sedatv/hyp/anxiolytc use, unsp w withdrawal, uncomplicated 20151001 22991231 F13931 Sedatv/hyp/anxiolytc use, unsp w withdrawal delirium 20151001 22991231 F13932 Sedatv/hyp/anxiolytc use, unsp w w/drawal w perceptl disturb 20151001 22991231 F13939 Sedatv/hyp/anxiolytc use, unsp w withdrawal, unsp 20151001 22991231 F1394 Sedative, hypnotic or anxiolytic use, unsp w mood disorder 20151001 22991231 F13950 Sedatv/hyp/anxiolytc use, unsp w psych disorder w delusions 20151001 22991231 F13951 Sedatv/hyp/anxiolytc use, unsp w psych disorder w hallucin 20151001 22991231 F13959 Sedatv/hyp/anxiolytc use, unsp w psychotic disorder, unsp 20151001 22991231 F1396 Sedatv/hyp/anxiolytc use, unsp w persist amnestic disorder 20151001 22991231 F1397 Sedatv/hyp/anxiolytc use, unsp w persisting dementia 20151001 22991231 F13980 Sedatv/hyp/anxiolytc use, unsp w anxiety disorder 20151001 22991231 F13981 Sedatv/hyp/anxiolytc use, unsp w sexual dysfunction 20151001 22991231 F13982 Sedative, hypnotic or anxiolytic use, unsp w sleep disorder 20151001 22991231 F13988 Sedative, hypnotic or anxiolytic use, unsp w oth disorder 20151001 22991231 F1399 Sedative, hypnotic or anxiolytic use, unsp w unsp disorder 20151001 22991231 F1410 Cocaine abuse, uncomplicated 20151001 22991231 F14120 Cocaine abuse with intoxication, uncomplicated 20151001 22991231 F14121 Cocaine abuse with intoxication with delirium 20151001 22991231 F14122 Cocaine abuse with intoxication with perceptual disturbance 20151001 22991231 F14129 Cocaine abuse with intoxication, unspecified 20151001 22991231 F1413 Cocaine abuse, unspecified with withdrawal 20201001 22991231 F1414 Cocaine abuse with cocaine-induced mood disorder 20151001 22991231 F14150 Cocaine abuse w cocaine-induc psychotic disorder w delusions 20151001 22991231 F14151 Cocaine abuse w cocaine-induc psychotic disorder w hallucin 20151001 22991231 F14159 Cocaine abuse with cocaine-induced psychotic disorder, unsp 20151001 22991231 F14180 Cocaine abuse with cocaine-induced anxiety disorder 20151001 22991231 F14181 Cocaine abuse with cocaine-induced sexual dysfunction 20151001 22991231 F14182 Cocaine abuse with cocaine-induced sleep disorder 20151001 22991231 F14188 Cocaine abuse with other cocaine-induced disorder 20151001 22991231
246 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1419 Cocaine abuse with unspecified cocaine-induced disorder 20151001 22991231 F1420 Cocaine dependence, uncomplicated 20151001 22991231 F1421 Cocaine dependence, in remission 20151001 22991231 F14220 Cocaine dependence with intoxication, uncomplicated 20151001 22991231 F14221 Cocaine dependence with intoxication delirium 20151001 22991231 F14222 Cocaine dependence w intoxication w perceptual disturbance 20151001 22991231 F14229 Cocaine dependence with intoxication, unspecified 20151001 22991231 F1423 Cocaine dependence with withdrawal 20151001 22991231 F1424 Cocaine dependence with cocaine-induced mood disorder 20151001 22991231 F14250 Cocaine depend w cocaine-induc psych disorder w delusions 20151001 22991231 F14251 Cocaine depend w cocaine-induc psychotic disorder w hallucin 20151001 22991231 F14259 Cocaine dependence w cocaine-induc psychotic disorder, unsp 20151001 22991231 F14280 Cocaine dependence with cocaine-induced anxiety disorder 20151001 22991231 F14281 Cocaine dependence with cocaine-induced sexual dysfunction 20151001 22991231 F14282 Cocaine dependence with cocaine-induced sleep disorder 20151001 22991231 F14288 Cocaine dependence with other cocaine-induced disorder 20151001 22991231 F1429 Cocaine dependence with unspecified cocaine-induced disorder 20151001 22991231 F1490 Cocaine use, unspecified, uncomplicated 20151001 22991231 F14920 Cocaine use, unspecified with intoxication, uncomplicated 20151001 22991231 F14921 Cocaine use, unspecified with intoxication delirium 20151001 22991231 F14922 Cocaine use, unsp w intoxication with perceptual disturbance 20151001 22991231 F14929 Cocaine use, unspecified with intoxication, unspecified 20151001 22991231 F1493 Cocaine use, unspecified with withdrawal 20201001 22991231 F1494 Cocaine use, unspecified with cocaine-induced mood disorder 20151001 22991231 F14950 Cocaine use, unsp w cocaine-induc psych disorder w delusions 20151001 22991231 F14951 Cocaine use, unsp w cocaine-induc psych disorder w hallucin 20151001 22991231 F14959 Cocaine use, unsp w cocaine-induced psychotic disorder, unsp 20151001 22991231 F14980 Cocaine use, unsp with cocaine-induced anxiety disorder 20151001 22991231 F14981 Cocaine use, unsp with cocaine-induced sexual dysfunction 20151001 22991231 F14982 Cocaine use, unspecified with cocaine-induced sleep disorder 20151001 22991231 F14988 Cocaine use, unspecified with other cocaine-induced disorder 20151001 22991231
247 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1499 Cocaine use, unsp with unspecified cocaine-induced disorder 20151001 22991231 F1510 Other stimulant abuse, uncomplicated 20151001 22991231 F15120 Other stimulant abuse with intoxication, uncomplicated 20151001 22991231 F15121 Other stimulant abuse with intoxication delirium 20151001 22991231 F15122 Oth stimulant abuse w intoxication w perceptual disturbance 20151001 22991231 F15129 Other stimulant abuse with intoxication, unspecified 20151001 22991231 F1513 Other stimulant abuse with withdrawal 20201001 22991231 F1514 Other stimulant abuse with stimulant-induced mood disorder 20151001 22991231 F15150 Oth stimulant abuse w stim-induce psych disorder w delusions 20151001 22991231 F15151 Oth stimulant abuse w stim-induce psych disorder w hallucin 20151001 22991231 F15159 Oth stimulant abuse w stim-induce psychotic disorder, unsp 20151001 22991231 F15180 Oth stimulant abuse with stimulant-induced anxiety disorder 20151001 22991231 F15181 Oth stimulant abuse w stimulant-induced sexual dysfunction 20151001 22991231 F15182 Other stimulant abuse with stimulant-induced sleep disorder 20151001 22991231 F15188 Other stimulant abuse with other stimulant-induced disorder 20151001 22991231 F1519 Other stimulant abuse with unsp stimulant-induced disorder 20151001 22991231 F1520 Other stimulant dependence, uncomplicated 20151001 22991231 F1521 Other stimulant dependence, in remission 20151001 22991231 F15220 Other stimulant dependence with intoxication, uncomplicated 20151001 22991231 F15221 Other stimulant dependence with intoxication delirium 20151001 22991231 F15222 Oth stimulant dependence w intox w perceptual disturbance 20151001 22991231 F15229 Other stimulant dependence with intoxication, unspecified 20151001 22991231 F1523 Other stimulant dependence with withdrawal 20151001 22991231 F1524 Oth stimulant dependence w stimulant-induced mood disorder 20151001 22991231 F15250 Oth stim depend w stim-induce psych disorder w delusions 20151001 22991231 F15251 Oth stimulant depend w stim-induce psych disorder w hallucin 20151001 22991231 F15259 Oth stimulant depend w stim-induce psychotic disorder, unsp 20151001 22991231 F15280 Oth stimulant dependence w stim-induce anxiety disorder 20151001 22991231 F15281 Oth stimulant dependence w stim-induce sexual dysfunction 20151001 22991231 F15282 Oth stimulant dependence w stimulant-induced sleep disorder 20151001 22991231 F15288 Oth stimulant dependence with oth stimulant-induced disorder 20151001 22991231
248 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1529 Oth stimulant dependence w unsp stimulant-induced disorder 20151001 22991231 F1590 Other stimulant use, unspecified, uncomplicated 20151001 22991231 F15920 Other stimulant use, unsp with intoxication, uncomplicated 20151001 22991231 F15921 Other stimulant use, unspecified with intoxication delirium 20151001 22991231 F15922 Oth stimulant use, unsp w intox w perceptual disturbance 20151001 22991231 F15929 Other stimulant use, unsp with intoxication, unspecified 20151001 22991231 F1593 Other stimulant use, unspecified with withdrawal 20151001 22991231 F1594 Oth stimulant use, unsp with stimulant-induced mood disorder 20151001 22991231 F15950 Oth stim use, unsp w stim-induce psych disorder w delusions 20151001 22991231 F15951 Oth stim use, unsp w stim-induce psych disorder w hallucin 20151001 22991231 F15959 Oth stimulant use, unsp w stim-induce psych disorder, unsp 20151001 22991231 F15980 Oth stimulant use, unsp w stimulant-induced anxiety disorder 20151001 22991231 F15981 Oth stimulant use, unsp w stim-induce sexual dysfunction 20151001 22991231 F15982 Oth stimulant use, unsp w stimulant-induced sleep disorder 20151001 22991231 F15988 Oth stimulant use, unsp with oth stimulant-induced disorder 20151001 22991231 F1599 Oth stimulant use, unsp with unsp stimulant-induced disorder 20151001 22991231 F1610 Hallucinogen abuse, uncomplicated 20151001 22991231 F16120 Hallucinogen abuse with intoxication, uncomplicated 20151001 22991231 F16121 Hallucinogen abuse with intoxication with delirium 20151001 22991231 F16122 Hallucinogen abuse w intoxication w perceptual disturbance 20151001 22991231 F16129 Hallucinogen abuse with intoxication, unspecified 20151001 22991231 F1614 Hallucinogen abuse with hallucinogen-induced mood disorder 20151001 22991231 F16150 Hallucinogen abuse w psychotic disorder w delusions 20151001 22991231 F16151 Hallucinogen abuse w psychotic disorder w hallucinations 20151001 22991231 F16159 Hallucinogen abuse w psychotic disorder, unsp 20151001 22991231 F16180 Hallucinogen abuse w hallucinogen-induced anxiety disorder 20151001 22991231 F16183 Hallucign abuse w hallucign persisting perception disorder 20151001 22991231 F16188 Hallucinogen abuse with other hallucinogen-induced disorder 20151001 22991231 F1619 Hallucinogen abuse with unsp hallucinogen-induced disorder 20151001 22991231 F1620 Hallucinogen dependence, uncomplicated 20151001 22991231 F1621 Hallucinogen dependence, in remission 20151001 22991231
249 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F16220 Hallucinogen dependence with intoxication, uncomplicated 20151001 22991231 F16221 Hallucinogen dependence with intoxication with delirium 20151001 22991231 F16229 Hallucinogen dependence with intoxication, unspecified 20151001 22991231 F1624 Hallucinogen dependence w hallucinogen-induced mood disorder 20151001 22991231 F16250 Hallucinogen dependence w psychotic disorder w delusions 20151001 22991231 F16251 Hallucinogen dependence w psychotic disorder w hallucin 20151001 22991231 F16259 Hallucinogen dependence w psychotic disorder, unsp 20151001 22991231 F16280 Hallucinogen dependence w anxiety disorder 20151001 22991231 F16283 Hallucign depend w hallucign persisting perception disorder 20151001 22991231 F16288 Hallucinogen dependence w oth hallucinogen-induced disorder 20151001 22991231 F1629 Hallucinogen dependence w unsp hallucinogen-induced disorder 20151001 22991231 F1690 Hallucinogen use, unspecified, uncomplicated 20151001 22991231 F16920 Hallucinogen use, unsp with intoxication, uncomplicated 20151001 22991231 F16921 Hallucinogen use, unsp with intoxication with delirium 20151001 22991231 F16929 Hallucinogen use, unspecified with intoxication, unspecified 20151001 22991231 F1694 Hallucinogen use, unsp w hallucinogen-induced mood disorder 20151001 22991231 F16950 Hallucinogen use, unsp w psychotic disorder w delusions 20151001 22991231 F16951 Hallucinogen use, unsp w psychotic disorder w hallucinations 20151001 22991231 F16959 Hallucinogen use, unsp w psychotic disorder, unsp 20151001 22991231 F16980 Hallucinogen use, unsp w anxiety disorder 20151001 22991231 F16983 Hallucign use, unsp w hallucign persist perception disorder 20151001 22991231 F16988 Hallucinogen use, unsp w oth hallucinogen-induced disorder 20151001 22991231 F1699 Hallucinogen use, unsp w unsp hallucinogen-induced disorder 20151001 22991231 F17200 Nicotine dependence, unspecified, uncomplicated 20151001 22991231 F17201 Nicotine dependence, unspecified, in remission 20151001 22991231 F17203 Nicotine dependence unspecified, with withdrawal 20151001 22991231 F17208 Nicotine dependence, unsp, w oth nicotine-induced disorders 20151001 22991231 F17209 Nicotine dependence, unsp, w unsp nicotine-induced disorders 20151001 22991231 F17210 Nicotine dependence, cigarettes, uncomplicated 20151001 22991231 F17211 Nicotine dependence, cigarettes, in remission 20151001 22991231 F17213 Nicotine dependence, cigarettes, with withdrawal 20151001 22991231
250 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F17218 Nicotine dependence, cigarettes, w oth disorders 20151001 22991231 F17219 Nicotine dependence, cigarettes, w unsp disorders 20151001 22991231 F17220 Nicotine dependence, chewing tobacco, uncomplicated 20151001 22991231 F17221 Nicotine dependence, chewing tobacco, in remission 20151001 22991231 F17223 Nicotine dependence, chewing tobacco, with withdrawal 20151001 22991231 F17228 Nicotine dependence, chewing tobacco, w oth disorders 20151001 22991231 F17229 Nicotine dependence, chewing tobacco, w unsp disorders 20151001 22991231 F17290 Nicotine dependence, other tobacco product, uncomplicated 20151001 22991231 F17291 Nicotine dependence, other tobacco product, in remission 20151001 22991231 F17293 Nicotine dependence, other tobacco product, with withdrawal 20151001 22991231 F17298 Nicotine dependence, oth tobacco product, w oth disorders 20151001 22991231 F17299 Nicotine dependence, oth tobacco product, w unsp disorders 20151001 22991231 F1810 Inhalant abuse, uncomplicated 20151001 22991231 F18120 Inhalant abuse with intoxication, uncomplicated 20151001 22991231 F18121 Inhalant abuse with intoxication delirium 20151001 22991231 F18129 Inhalant abuse with intoxication, unspecified 20151001 22991231 F1814 Inhalant abuse with inhalant-induced mood disorder 20151001 22991231 F18150 Inhalant abuse w inhalnt-induce psych disorder w delusions 20151001 22991231 F18151 Inhalant abuse w inhalnt-induce psych disorder w hallucin 20151001 22991231 F18159 Inhalant abuse w inhalant-induced psychotic disorder, unsp 20151001 22991231 F1817 Inhalant abuse with inhalant-induced dementia 20151001 22991231 F18180 Inhalant abuse with inhalant-induced anxiety disorder 20151001 22991231 F18188 Inhalant abuse with other inhalant-induced disorder 20151001 22991231 F1819 Inhalant abuse with unspecified inhalant-induced disorder 20151001 22991231 F1820 Inhalant dependence, uncomplicated 20151001 22991231 F1821 Inhalant dependence, in remission 20151001 22991231 F18220 Inhalant dependence with intoxication, uncomplicated 20151001 22991231 F18221 Inhalant dependence with intoxication delirium 20151001 22991231 F18229 Inhalant dependence with intoxication, unspecified 20151001 22991231 F1824 Inhalant dependence with inhalant-induced mood disorder 20151001 22991231 F18250 Inhalant depend w inhalnt-induce psych disorder w delusions 20151001 22991231
251 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F18251 Inhalant depend w inhalnt-induce psych disorder w hallucin 20151001 22991231 F18259 Inhalant depend w inhalnt-induce psychotic disorder, unsp 20151001 22991231 F1827 Inhalant dependence with inhalant-induced dementia 20151001 22991231 F18280 Inhalant dependence with inhalant-induced anxiety disorder 20151001 22991231 F18288 Inhalant dependence with other inhalant-induced disorder 20151001 22991231 F1829 Inhalant dependence with unsp inhalant-induced disorder 20151001 22991231 F1890 Inhalant use, unspecified, uncomplicated 20151001 22991231 F18920 Inhalant use, unspecified with intoxication, uncomplicated 20151001 22991231 F18921 Inhalant use, unspecified with intoxication with delirium 20151001 22991231 F18929 Inhalant use, unspecified with intoxication, unspecified 20151001 22991231 F1894 Inhalant use, unsp with inhalant-induced mood disorder 20151001 22991231 F18950 Inhalant use, unsp w inhalnt-induce psych disord w delusions 20151001 22991231 F18951 Inhalant use, unsp w inhalnt-induce psych disord w hallucin 20151001 22991231 F18959 Inhalant use, unsp w inhalnt-induce psychotic disorder, unsp 20151001 22991231 F1897 Inhalant use, unsp with inhalant-induced persisting dementia 20151001 22991231 F18980 Inhalant use, unsp with inhalant-induced anxiety disorder 20151001 22991231 F18988 Inhalant use, unsp with other inhalant-induced disorder 20151001 22991231 F1899 Inhalant use, unsp with unsp inhalant-induced disorder 20151001 22991231 F1910 Other psychoactive substance abuse, uncomplicated 20151001 22991231 F19120 Oth psychoactive substance abuse w intoxication, uncomp 20151001 22991231 F19121 Oth psychoactive substance abuse with intoxication delirium 20151001 22991231 F19122 Oth psychoactv substance abuse w intox w perceptual disturb 20151001 22991231 F19129 Other psychoactive substance abuse with intoxication, unsp 20151001 22991231 F19130 Other psychoactive substance abuse with withdrawal, uncomp 20201001 22991231 F19131 Other psychoactive substance abuse with withdrawal delirium 20201001 22991231 F19132 Other psychoactv sub abuse with w/drawal w perceptl disturb 20201001 22991231 F19139 Other psychoactv substance abuse with withdrawal, unsp 20201001 22991231 F1914 Oth psychoactive substance abuse w mood disorder 20151001 22991231 F19150 Oth psychoactv substance abuse w psych disorder w delusions 20151001 22991231 F19151 Oth psychoactv substance abuse w psych disorder w hallucin 20151001 22991231 F19159 Oth psychoactive substance abuse w psychotic disorder, unsp 20151001 22991231
252 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1916 Oth psychoactv substance abuse w persist amnestic disorder 20151001 22991231 F1917 Oth psychoactive substance abuse w persisting dementia 20151001 22991231 F19180 Oth psychoactive substance abuse w anxiety disorder 20151001 22991231 F19181 Oth psychoactive substance abuse w sexual dysfunction 20151001 22991231 F19182 Oth psychoactive substance abuse w sleep disorder 20151001 22991231 F19188 Oth psychoactive substance abuse w oth disorder 20151001 22991231 F1919 Oth psychoactive substance abuse w unsp disorder 20151001 22991231 F1920 Other psychoactive substance dependence, uncomplicated 20151001 22991231 F1921 Other psychoactive substance dependence, in remission 20151001 22991231 F19220 Oth psychoactive substance dependence w intoxication, uncomp 20151001 22991231 F19221 Oth psychoactive substance dependence w intox delirium 20151001 22991231 F19222 Oth psychoactv substance depend w intox w perceptual disturb 20151001 22991231 F19229 Oth psychoactive substance dependence w intoxication, unsp 20151001 22991231 F19230 Oth psychoactive substance dependence w withdrawal, uncomp 20151001 22991231 F19231 Oth psychoactive substance dependence w withdrawal delirium 20151001 22991231 F19232 Oth psychoactv sub depend w w/drawal w perceptl disturb 20151001 22991231 F19239 Oth psychoactive substance dependence with withdrawal, unsp 20151001 22991231 F1924 Oth psychoactive substance dependence w mood disorder 20151001 22991231 F19250 Oth psychoactv substance depend w psych disorder w delusions 20151001 22991231 F19251 Oth psychoactv substance depend w psych disorder w hallucin 20151001 22991231 F19259 Oth psychoactv substance depend w psychotic disorder, unsp 20151001 22991231 F1926 Oth psychoactv substance depend w persist amnestic disorder 20151001 22991231 F1927 Oth psychoactive substance dependence w persisting dementia 20151001 22991231 F19280 Oth psychoactive substance dependence w anxiety disorder 20151001 22991231 F19281 Oth psychoactive substance dependence w sexual dysfunction 20151001 22991231 F19282 Oth psychoactive substance dependence w sleep disorder 20151001 22991231 F19288 Oth psychoactive substance dependence w oth disorder 20151001 22991231 F1929 Oth psychoactive substance dependence w unsp disorder 20151001 22991231 F1990 Other psychoactive substance use, unspecified, uncomplicated 20151001 22991231 F19920 Oth psychoactive substance use, unsp w intoxication, uncomp 20151001 22991231 F19921 Oth psychoactive substance use, unsp w intox w delirium 20151001 22991231
253 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F19922 Oth psychoactv sub use, unsp w intox w perceptl disturb 20151001 22991231 F19929 Oth psychoactive substance use, unsp with intoxication, unsp 20151001 22991231 F19930 Oth psychoactive substance use, unsp w withdrawal, uncomp 20151001 22991231 F19931 Oth psychoactive substance use, unsp w withdrawal delirium 20151001 22991231 F19932 Oth psychoactv sub use, unsp w w/drawal w perceptl disturb 20151001 22991231 F19939 Other psychoactive substance use, unsp with withdrawal, unsp 20151001 22991231 F1994 Oth psychoactive substance use, unsp w mood disorder 20151001 22991231 F19950 Oth psychoactv sub use, unsp w psych disorder w delusions 20151001 22991231 F19951 Oth psychoactv sub use, unsp w psych disorder w hallucin 20151001 22991231 F19959 Oth psychoactv substance use, unsp w psych disorder, unsp 20151001 22991231 F1996 Oth psychoactv sub use, unsp w persist amnestic disorder 20151001 22991231 F1997 Oth psychoactive substance use, unsp w persisting dementia 20151001 22991231 F19980 Oth psychoactive substance use, unsp w anxiety disorder 20151001 22991231 F19981 Oth psychoactive substance use, unsp w sexual dysfunction 20151001 22991231 F19982 Oth psychoactive substance use, unsp w sleep disorder 20151001 22991231 F19988 Oth psychoactive substance use, unsp w oth disorder 20151001 22991231 F1999 Oth psychoactive substance use, unsp w unsp disorder 20151001 22991231 F200 Paranoid schizophrenia 20151001 22991231 F201 Disorganized schizophrenia 20151001 22991231 F202 Catatonic schizophrenia 20151001 22991231 F203 Undifferentiated schizophrenia 20151001 22991231 F205 Residual schizophrenia 20151001 22991231 F2081 Schizophreniform disorder 20151001 22991231 F2089 Other schizophrenia 20151001 22991231 F209 Schizophrenia, unspecified 20151001 22991231 F21 Schizotypal disorder 20151001 22991231 F22 Delusional disorders 20151001 22991231 F23 Brief psychotic disorder 20151001 22991231 F24 Shared psychotic disorder 20151001 22991231 F250 Schizoaffective disorder, bipolar type 20151001 22991231 F251 Schizoaffective disorder, depressive type 20151001 22991231
254 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F258 Other schizoaffective disorders 20151001 22991231 F259 Schizoaffective disorder, unspecified 20151001 22991231 F28 Oth psych disorder not due to a sub or known physiol cond 20151001 22991231 F29 Unsp psychosis not due to a substance or known physiol cond 20151001 22991231 F3010 Manic episode without psychotic symptoms, unspecified 20151001 22991231 F3011 Manic episode without psychotic symptoms, mild 20151001 22991231 F3012 Manic episode without psychotic symptoms, moderate 20151001 22991231 F3013 Manic episode, severe, without psychotic symptoms 20151001 22991231 F302 Manic episode, severe with psychotic symptoms 20151001 22991231 F303 Manic episode in partial remission 20151001 22991231 F304 Manic episode in full remission 20151001 22991231 F308 Other manic episodes 20151001 22991231 F309 Manic episode, unspecified 20151001 22991231 F310 Bipolar disorder, current episode hypomanic 20151001 22991231 F3110 Bipolar disord, crnt episode manic w/o psych features, unsp 20151001 22991231 F3111 Bipolar disord, crnt episode manic w/o psych features, mild 20151001 22991231 F3112 Bipolar disord, crnt episode manic w/o psych features, mod 20151001 22991231 F3113 Bipolar disord, crnt epsd manic w/o psych features, severe 20151001 22991231 F312 Bipolar disord, crnt episode manic severe w psych features 20151001 22991231 F3130 Bipolar disord, crnt epsd depress, mild or mod severt, unsp 20151001 22991231 F3131 Bipolar disorder, current episode depressed, mild 20151001 22991231 F3132 Bipolar disorder, current episode depressed, moderate 20151001 22991231 F314 Bipolar disord, crnt epsd depress, sev, w/o psych features 20151001 22991231 F315 Bipolar disord, crnt epsd depress, severe, w psych features 20151001 22991231 F3160 Bipolar disorder, current episode mixed, unspecified 20151001 22991231 F3161 Bipolar disorder, current episode mixed, mild 20151001 22991231 F3162 Bipolar disorder, current episode mixed, moderate 20151001 22991231 F3163 Bipolar disord, crnt epsd mixed, severe, w/o psych features 20151001 22991231 F3164 Bipolar disord, crnt episode mixed, severe, w psych features 20151001 22991231 F3170 Bipolar disord, currently in remis, most recent episode unsp 20151001 22991231 F3171 Bipolar disord, in partial remis, most recent epsd hypomanic 20151001 22991231
255 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F3172 Bipolar disord, in full remis, most recent episode hypomanic 20151001 22991231 F3173 Bipolar disord, in partial remis, most recent episode manic 20151001 22991231 F3174 Bipolar disorder, in full remis, most recent episode manic 20151001 22991231 F3175 Bipolar disord, in partial remis, most recent epsd depress 20151001 22991231 F3176 Bipolar disorder, in full remis, most recent episode depress 20151001 22991231 F3177 Bipolar disord, in partial remis, most recent episode mixed 20151001 22991231 F3178 Bipolar disorder, in full remis, most recent episode mixed 20151001 22991231 F3181 Bipolar II disorder 20151001 22991231 F3189 Other bipolar disorder 20151001 22991231 F319 Bipolar disorder, unspecified 20151001 22991231 F320 Major depressive disorder, single episode, mild 20151001 22991231 F321 Major depressive disorder, single episode, moderate 20151001 22991231 F322 Major depressv disord, single epsd, sev w/o psych features 20151001 22991231 F323 Major depressv disord, single epsd, severe w psych features 20151001 22991231 F324 Major depressv disorder, single episode, in partial remis 20151001 22991231 F325 Major depressive disorder, single episode, in full remission 20151001 22991231 F328 Other depressive episodes 20151001 20160930 F3281 Premenstrual dysphoric disorder 20161001 22991231 F3289 Other specified depressive episodes 20161001 22991231 F329 Major depressive disorder, single episode, unspecified 20151001 22991231 F330 Major depressive disorder, recurrent, mild 20151001 22991231 F331 Major depressive disorder, recurrent, moderate 20151001 22991231 F332 Major depressv disorder, recurrent severe w/o psych features 20151001 22991231 F333 Major depressv disorder, recurrent, severe w psych symptoms 20151001 22991231 F3340 Major depressive disorder, recurrent, in remission, unsp 20151001 22991231 F3341 Major depressive disorder, recurrent, in partial remission 20151001 22991231 F3342 Major depressive disorder, recurrent, in full remission 20151001 22991231 F338 Other recurrent depressive disorders 20151001 22991231 F339 Major depressive disorder, recurrent, unspecified 20151001 22991231 F340 Cyclothymic disorder 20151001 22991231 F341 Dysthymic disorder 20151001 22991231
256 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F348 Other persistent mood [affective] disorders 20151001 20160930 F3481 Disruptive mood dysregulation disorder 20161001 22991231 F3489 Other specified persistent mood disorders 20161001 22991231 F349 Persistent mood [affective] disorder, unspecified 20151001 22991231 F39 Unspecified mood [affective] disorder 20151001 22991231 F4000 Agoraphobia, unspecified 20151001 22991231 F4001 Agoraphobia with panic disorder 20151001 22991231 F4002 Agoraphobia without panic disorder 20151001 22991231 F4010 Social phobia, unspecified 20151001 22991231 F4011 Social phobia, generalized 20151001 22991231 F40210 Arachnophobia 20151001 22991231 F40218 Other animal type phobia 20151001 22991231 F40220 Fear of thunderstorms 20151001 22991231 F40228 Other natural environment type phobia 20151001 22991231 F40230 Fear of blood 20151001 22991231 F40231 Fear of injections and transfusions 20151001 22991231 F40232 Fear of other medical care 20151001 22991231 F40233 Fear of injury 20151001 22991231 F40240 Claustrophobia 20151001 22991231 F40241 Acrophobia 20151001 22991231 F40242 Fear of bridges 20151001 22991231 F40243 Fear of flying 20151001 22991231 F40248 Other situational type phobia 20151001 22991231 F40290 Androphobia 20151001 22991231 F40291 Gynephobia 20151001 22991231 F40298 Other specified phobia 20151001 22991231 F408 Other phobic anxiety disorders 20151001 22991231 F409 Phobic anxiety disorder, unspecified 20151001 22991231 F410 Panic disorder [episodic paroxysmal anxiety] 20151001 22991231 F411 Generalized anxiety disorder 20151001 22991231 F413 Other mixed anxiety disorders 20151001 22991231
257 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F418 Other specified anxiety disorders 20151001 22991231 F419 Anxiety disorder, unspecified 20151001 22991231 F42 Obsessive-compulsive disorder 20151001 20160930 F422 Mixed obsessional thoughts and acts 20161001 22991231 F423 Hoarding disorder 20161001 22991231 F424 Excoriation (skin-picking) disorder 20161001 22991231 F428 Other obsessive-compulsive disorder 20161001 22991231 F429 Obsessive-compulsive disorder, unspecified 20161001 22991231 F430 Acute stress reaction 20151001 22991231 F4310 Post-traumatic stress disorder, unspecified 20151001 22991231 F4311 Post-traumatic stress disorder, acute 20151001 22991231 F4312 Post-traumatic stress disorder, chronic 20151001 22991231 F4320 Adjustment disorder, unspecified 20151001 22991231 F4321 Adjustment disorder with depressed mood 20151001 22991231 F4322 Adjustment disorder with anxiety 20151001 22991231 F4323 Adjustment disorder with mixed anxiety and depressed mood 20151001 22991231 F4324 Adjustment disorder with disturbance of conduct 20151001 22991231 F4325 Adjustment disorder w mixed disturb of emotions and conduct 20151001 22991231 F4329 Adjustment disorder with other symptoms 20151001 22991231 F438 Other reactions to severe stress 20151001 22991231 F439 Reaction to severe stress, unspecified 20151001 22991231 F440 Dissociative amnesia 20151001 22991231 F441 Dissociative fugue 20151001 22991231 F442 Dissociative stupor 20151001 22991231 F444 Conversion disorder with motor symptom or deficit 20151001 22991231 F445 Conversion disorder with seizures or convulsions 20151001 22991231 F446 Conversion disorder with sensory symptom or deficit 20151001 22991231 F447 Conversion disorder with mixed symptom presentation 20151001 22991231 F4481 Dissociative identity disorder 20151001 22991231 F4489 Other dissociative and conversion disorders 20151001 22991231 F449 Dissociative and conversion disorder, unspecified 20151001 22991231
258 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F450 Somatization disorder 20151001 22991231 F451 Undifferentiated somatoform disorder 20151001 22991231 F4520 Hypochondriacal disorder, unspecified 20151001 22991231 F4521 Hypochondriasis 20151001 22991231 F4522 Body dysmorphic disorder 20151001 22991231 F4529 Other hypochondriacal disorders 20151001 22991231 F4541 Pain disorder exclusively related to psychological factors 20151001 22991231 F4542 Pain disorder with related psychological factors 20151001 22991231 F458 Other somatoform disorders 20151001 22991231 F459 Somatoform disorder, unspecified 20151001 22991231 F481 Depersonalization-derealization syndrome 20151001 22991231 F482 Pseudobulbar affect 20151001 22991231 F5000 Anorexia nervosa, unspecified 20151001 22991231 F5001 Anorexia nervosa, restricting type 20151001 22991231 F5002 Anorexia nervosa, binge eating/purging type 20151001 22991231 F502 Bulimia nervosa 20151001 22991231 F508 Other eating disorders 20151001 20160930 F515 Nightmare disorder 20151001 22991231 F520 Hypoactive sexual desire disorder 20151001 22991231 F521 Sexual aversion disorder 20151001 22991231 F53 Puerperal psychosis 20151001 20180930 F530 Postpartum depression 20181001 22991231 F531 Puerperal psychosis 20181001 22991231 F54 Psych & behavrl factors assoc w disord or dis classd elswhr 20151001 22991231 F550 Abuse of antacids 20151001 22991231 F551 Abuse of herbal or folk remedies 20151001 22991231 F552 Abuse of laxatives 20151001 22991231 F553 Abuse of steroids or hormones 20151001 22991231 F554 Abuse of vitamins 20151001 22991231 F558 Abuse of other non-psychoactive substances 20151001 22991231 F59 Unsp behavrl synd assoc w physiol disturb and physcl factors 20151001 22991231
259 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F600 Paranoid personality disorder 20151001 22991231 F601 Schizoid personality disorder 20151001 22991231 F602 Antisocial personality disorder 20151001 22991231 F603 Borderline personality disorder 20151001 22991231 F604 Histrionic personality disorder 20151001 22991231 F605 Obsessive-compulsive personality disorder 20151001 22991231 F606 Avoidant personality disorder 20151001 22991231 F607 Dependent personality disorder 20151001 22991231 F6081 Narcissistic personality disorder 20151001 22991231 F6089 Other specific personality disorders 20151001 22991231 F609 Personality disorder, unspecified 20151001 22991231 F630 Pathological gambling 20151001 22991231 F631 Pyromania 20151001 22991231 F632 Kleptomania 20151001 22991231 F633 Trichotillomania 20151001 22991231 F6381 Intermittent explosive disorder 20151001 22991231 F6389 Other impulse disorders 20151001 22991231 F639 Impulse disorder, unspecified 20151001 22991231 F641 Dual role transvestism 20151001 22991231 F642 Gender identity disorder of childhood 20151001 22991231 F648 Other gender identity disorders 20151001 22991231 F649 Gender identity disorder, unspecified 20151001 22991231 F650 Fetishism 20151001 22991231 F651 Transvestic fetishism 20151001 22991231 F652 Exhibitionism 20151001 22991231 F653 Voyeurism 20151001 22991231 F654 Pedophilia 20151001 22991231 F6550 Sadomasochism, unspecified 20151001 22991231 F6551 Sexual masochism 20151001 22991231 F6552 Sexual sadism 20151001 22991231 F6581 Frotteurism 20151001 22991231
260 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F6589 Other paraphilias 20151001 22991231 F659 Paraphilia, unspecified 20151001 22991231 F6810 Factitious disorder imposed on self, unspecified 20151001 22991231 F6811 Factit disord imposed on self, with predom psych signs/symp 20151001 22991231 F6812 Factit disord impsd on self, with predom physcl signs/symp 20151001 22991231 F6813 Factit disord impsd on self,w comb psych & physcl signs/symp 20151001 22991231 F688 Other specified disorders of adult personality and behavior 20151001 22991231 F68A Factitious disorder imposed on another 20181001 22991231 F69 Unspecified disorder of adult personality and behavior 20151001 22991231 F70 Mild intellectual disabilities 20151001 22991231 F71 Moderate intellectual disabilities 20151001 22991231 F72 Severe intellectual disabilities 20151001 22991231 F73 Profound intellectual disabilities 20151001 22991231 F78 Other intellectual disabilities 20151001 22991231 F79 Unspecified intellectual disabilities 20151001 22991231 F800 Phonological disorder 20151001 22991231 F801 Expressive language disorder 20151001 22991231 F802 Mixed receptive-expressive language disorder 20151001 22991231 F804 Speech and language development delay due to hearing loss 20151001 22991231 F8081 Childhood onset fluency disorder 20151001 22991231 F8089 Other developmental disorders of speech and language 20151001 22991231 F809 Developmental disorder of speech and language, unspecified 20151001 22991231 F82 Specific developmental disorder of motor function 20151001 22991231 F840 Autistic disorder 20151001 22991231 F843 Other childhood disintegrative disorder 20151001 22991231 F845 Asperger's syndrome 20151001 22991231 F848 Other pervasive developmental disorders 20151001 22991231 F849 Pervasive developmental disorder, unspecified 20151001 22991231 F88 Other disorders of psychological development 20151001 22991231 F89 Unspecified disorder of psychological development 20151001 22991231 F900 Attn-defct hyperactivity disorder, predom inattentive type 20151001 22991231
261 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F901 Attn-defct hyperactivity disorder, predom hyperactive type 20151001 22991231 F902 Attention-deficit hyperactivity disorder, combined type 20151001 22991231 F908 Attention-deficit hyperactivity disorder, other type 20151001 22991231 F909 Attention-deficit hyperactivity disorder, unspecified type 20151001 22991231 F910 Conduct disorder confined to family context 20151001 22991231 F911 Conduct disorder, childhood-onset type 20151001 22991231 F912 Conduct disorder, adolescent-onset type 20151001 22991231 F913 Oppositional defiant disorder 20151001 22991231 F918 Other conduct disorders 20151001 22991231 F919 Conduct disorder, unspecified 20151001 22991231 F930 Separation anxiety disorder of childhood 20151001 22991231 F938 Other childhood emotional disorders 20151001 22991231 F939 Childhood emotional disorder, unspecified 20151001 22991231 F940 Selective mutism 20151001 22991231 F941 Reactive attachment disorder of childhood 20151001 22991231 F942 Disinhibited attachment disorder of childhood 20151001 22991231 F948 Other childhood disorders of social functioning 20151001 22991231 F949 Childhood disorder of social functioning, unspecified 20151001 22991231 F950 Transient tic disorder 20151001 22991231 F951 Chronic motor or vocal tic disorder 20151001 22991231 F952 Tourette's disorder 20151001 22991231 F958 Other tic disorders 20151001 22991231 F959 Tic disorder, unspecified 20151001 22991231 F980 Enuresis not due to a substance or known physiol condition 20151001 22991231 F981 Encopresis not due to a substance or known physiol condition 20151001 22991231 F9821 Rumination disorder of infancy 20151001 22991231 F9829 Other feeding disorders of infancy and early childhood 20151001 22991231 F983 Pica of infancy and childhood 20151001 22991231 F984 Stereotyped movement disorders 20151001 22991231 F985 Adult onset fluency disorder 20151001 22991231 F988 Oth behav/emotn disord w onset usly occur in chldhd and adol 20151001 22991231
262 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F989 Unsp behav/emotn disord w onst usly occur in chldhd and adol 20151001 22991231 F99 Mental disorder, not otherwise specified 20151001 22991231 G44209 Tension-type headache, unspecified, not intractable 20151001 22991231 H9325 Central auditory processing disorder 20151001 22991231 M4321 Fusion of spine, occipito-atlanto-axial region 20151001 22991231 M4322 Fusion of spine, cervical region 20151001 22991231 M4323 Fusion of spine, cervicothoracic region 20151001 22991231 M4324 Fusion of spine, thoracic region 20151001 22991231 M4325 Fusion of spine, thoracolumbar region 20151001 22991231 M4326 Fusion of spine, lumbar region 20151001 22991231 M4327 Fusion of spine, lumbosacral region 20151001 22991231 M4328 Fusion of spine, sacral and sacrococcygeal region 20151001 22991231 M436 Torticollis 20151001 22991231 M438X1 Oth deforming dorsopathies, occipito-atlanto-axial region 20151001 22991231 M438X2 Other specified deforming dorsopathies, cervical region 20151001 22991231 M438X3 Oth deforming dorsopathies, cervicothoracic region 20151001 22991231 M438X4 Other specified deforming dorsopathies, thoracic region 20151001 22991231 M438X5 Other specified deforming dorsopathies, thoracolumbar region 20151001 22991231 M438X6 Other specified deforming dorsopathies, lumbar region 20151001 22991231 M438X7 Other specified deforming dorsopathies, lumbosacral region 20151001 22991231 M438X8 Oth deforming dorsopathies, sacral and sacrococcygeal region 20151001 22991231 M438X9 Other specified deforming dorsopathies, site unspecified 20151001 22991231 M4640 Discitis, unspecified, site unspecified 20151001 22991231 M4641 Discitis, unspecified, occipito-atlanto-axial region 20151001 22991231 M4642 Discitis, unspecified, cervical region 20151001 22991231 M4643 Discitis, unspecified, cervicothoracic region 20151001 22991231 M4644 Discitis, unspecified, thoracic region 20151001 22991231 M4645 Discitis, unspecified, thoracolumbar region 20151001 22991231 M4646 Discitis, unspecified, lumbar region 20151001 22991231 M4647 Discitis, unspecified, lumbosacral region 20151001 22991231 M4648 Discitis, unspecified, sacral and sacrococcygeal region 20151001 22991231
263 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M4649 Discitis, unspecified, multiple sites in spine 20151001 22991231 M4800 Spinal stenosis, site unspecified 20151001 22991231 M4801 Spinal stenosis, occipito-atlanto-axial region 20151001 22991231 M4802 Spinal stenosis, cervical region 20151001 22991231 M4803 Spinal stenosis, cervicothoracic region 20151001 22991231 M4804 Spinal stenosis, thoracic region 20151001 22991231 M4805 Spinal stenosis, thoracolumbar region 20151001 22991231 M4806 Spinal stenosis, lumbar region 20151001 20170930 M48061 Spinal stenosis, lumbar region without neurogenic claud 20171001 22991231 M48062 Spinal stenosis, lumbar region with neurogenic claudication 20171001 22991231 M4807 Spinal stenosis, lumbosacral region 20151001 22991231 M4808 Spinal stenosis, sacral and sacrococcygeal region 20151001 22991231 M5000 Cervical disc disorder with myelopathy, unsp cervical region 20151001 22991231 M5001 Cervical disc disorder with myelopathy, high cervical region 20151001 22991231 M5002 Cervical disc disorder with myelopathy, mid-cervical region 20151001 20160930 M50020 Cerv disc disord with myelpath, mid-cervical rgn, unsp level 20161001 22991231 M50021 Cervical disc disorder at C4-C5 level with myelopathy 20161001 22991231 M50022 Cervical disc disorder at C5-C6 level with myelopathy 20161001 22991231 M50023 Cervical disc disorder at C6-C7 level with myelopathy 20161001 22991231 M5003 Cervical disc disorder w myelopathy, cervicothoracic region 20151001 22991231 M5010 Cervical disc disorder w radiculopathy, unsp cervical region 20151001 22991231 M5011 Cerv disc disorder with radiculopathy, high cervical region 20151001 22991231 M5012 Cervical disc disorder w radiculopathy, mid-cervical region 20151001 20160930 M50120 Mid-cervical disc disorder, unspecified level 20161001 22991231 M50121 Cervical disc disorder at C4-C5 level with radiculopathy 20161001 22991231 M50122 Cervical disc disorder at C5-C6 level with radiculopathy 20161001 22991231 M50123 Cervical disc disorder at C6-C7 level with radiculopathy 20161001 22991231 M5013 Cervical disc disorder w radiculopathy, cervicothor region 20151001 22991231 M5020 Other cervical disc displacement, unsp cervical region 20151001 22991231 M5021 Other cervical disc displacement, high cervical region 20151001 22991231 M5022 Other cervical disc displacement, mid-cervical region 20151001 20160930
264 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M50220 Other cerv disc displacmnt, mid-cervical region, unsp level 20161001 22991231 M50221 Other cervical disc displacement at C4-C5 level 20161001 22991231 M50222 Other cervical disc displacement at C5-C6 level 20161001 22991231 M50223 Other cervical disc displacement at C6-C7 level 20161001 22991231 M5023 Other cervical disc displacement, cervicothoracic region 20151001 22991231 M5030 Other cervical disc degeneration, unsp cervical region 20151001 22991231 M5031 Other cervical disc degeneration, high cervical region 20151001 22991231 M5032 Other cervical disc degeneration, mid-cervical region 20151001 20160930 M50320 Other cerv disc degeneration, mid-cervical rgn, unsp level 20161001 22991231 M50321 Other cervical disc degeneration at C4-C5 level 20161001 22991231 M50322 Other cervical disc degeneration at C5-C6 level 20161001 22991231 M50323 Other cervical disc degeneration at C6-C7 level 20161001 22991231 M5033 Other cervical disc degeneration, cervicothoracic region 20151001 22991231 M5080 Other cervical disc disorders, unspecified cervical region 20151001 22991231 M5081 Other cervical disc disorders, high cervical region 20151001 22991231 M5082 Other cervical disc disorders, mid-cervical region 20151001 20160930 M50820 Other cervical disc disord, mid-cervical region, unsp level 20161001 22991231 M50821 Other cervical disc disorders at C4-C5 level 20161001 22991231 M50822 Other cervical disc disorders at C5-C6 level 20161001 22991231 M50823 Other cervical disc disorders at C6-C7 level 20161001 22991231 M5083 Other cervical disc disorders, cervicothoracic region 20151001 22991231 M5090 Cervical disc disorder, unsp, unspecified cervical region 20151001 22991231 M5091 Cervical disc disorder, unspecified, high cervical region 20151001 22991231 M5092 Cervical disc disorder, unspecified, mid-cervical region 20151001 20160930 M50920 Unsp cervical disc disorder, mid-cervical region, unsp level 20161001 22991231 M50921 Unspecified cervical disc disorder at C4-C5 level 20161001 22991231 M50922 Unspecified cervical disc disorder at C5-C6 level 20161001 22991231 M50923 Unspecified cervical disc disorder at C6-C7 level 20161001 22991231 M5093 Cervical disc disorder, unspecified, cervicothoracic region 20151001 22991231 M5104 Intervertebral disc disorders w myelopathy, thoracic region 20151001 22991231 M5105 Intvrt disc disorders w myelopathy, thoracolumbar region 20151001 22991231
265 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M5106 Intervertebral disc disorders with myelopathy, lumbar region 20151001 22991231 M5114 Intvrt disc disorders w radiculopathy, thoracic region 20151001 22991231 M5115 Intvrt disc disorders w radiculopathy, thoracolumbar region 20151001 22991231 M5116 Intervertebral disc disorders w radiculopathy, lumbar region 20151001 22991231 M5117 Intvrt disc disorders w radiculopathy, lumbosacral region 20151001 22991231 M5124 Other intervertebral disc displacement, thoracic region 20151001 22991231 M5125 Other intervertebral disc displacement, thoracolumbar region 20151001 22991231 M5126 Other intervertebral disc displacement, lumbar region 20151001 22991231 M5127 Other intervertebral disc displacement, lumbosacral region 20151001 22991231 M5134 Other intervertebral disc degeneration, thoracic region 20151001 22991231 M5135 Other intervertebral disc degeneration, thoracolumbar region 20151001 22991231 M5136 Other intervertebral disc degeneration, lumbar region 20151001 22991231 M5137 Other intervertebral disc degeneration, lumbosacral region 20151001 22991231 M5144 Schmorl's nodes, thoracic region 20151001 22991231 M5145 Schmorl's nodes, thoracolumbar region 20151001 22991231 M5146 Schmorl's nodes, lumbar region 20151001 22991231 M5147 Schmorl's nodes, lumbosacral region 20151001 22991231 M5184 Other intervertebral disc disorders, thoracic region 20151001 22991231 M5185 Other intervertebral disc disorders, thoracolumbar region 20151001 22991231 M5186 Other intervertebral disc disorders, lumbar region 20151001 22991231 M5187 Other intervertebral disc disorders, lumbosacral region 20151001 22991231 M519 Unsp thoracic, thoracolum and lumbosacr intvrt disc disorder 20151001 22991231 M530 Cervicocranial syndrome 20151001 22991231 M531 Cervicobrachial syndrome 20151001 22991231 M532X7 Spinal instabilities, lumbosacral region 20151001 22991231 M532X8 Spinal instabilities, sacral and sacrococcygeal region 20151001 22991231 M533 Sacrococcygeal disorders, not elsewhere classified 20151001 22991231 M5380 Other specified dorsopathies, site unspecified 20151001 22991231 M5381 Other specified dorsopathies, occipito-atlanto-axial region 20151001 22991231 M5382 Other specified dorsopathies, cervical region 20151001 22991231 M5383 Other specified dorsopathies, cervicothoracic region 20151001 22991231
266 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M5384 Other specified dorsopathies, thoracic region 20151001 22991231 M5385 Other specified dorsopathies, thoracolumbar region 20151001 22991231 M5386 Other specified dorsopathies, lumbar region 20151001 22991231 M5387 Other specified dorsopathies, lumbosacral region 20151001 22991231 M5388 Oth dorsopathies, sacral and sacrococcygeal region 20151001 22991231 M539 Dorsopathy, unspecified 20151001 22991231 M5400 Panniculitis affecting regions of neck and back, site unsp 20151001 22991231 M5401 Panniculitis aff regions of neck/bk, occipt-atlan-ax region 20151001 22991231 M5402 Panniculitis affecting regions of neck/bk, cervical region 20151001 22991231 M5403 Panniculitis aff regions of neck/bk, cervicothor region 20151001 22991231 M5404 Panniculitis affecting regions of neck/bk, thoracic region 20151001 22991231 M5405 Panniculitis affecting regions of neck/bk, thoracolum region 20151001 22991231 M5406 Panniculitis affecting regions of neck/bk, lumbar region 20151001 22991231 M5407 Panniculitis affecting regions of neck/bk, lumbosacr region 20151001 22991231 M5408 Panniculitis aff regions of neck/bk, sacr/sacrocygl region 20151001 22991231 M5409 Panniculitis aff regions, neck/bk, multiple sites in spine 20151001 22991231 M5411 Radiculopathy, occipito-atlanto-axial region 20151001 22991231 M5412 Radiculopathy, cervical region 20151001 22991231 M5413 Radiculopathy, cervicothoracic region 20151001 22991231 M5414 Radiculopathy, thoracic region 20151001 22991231 M5415 Radiculopathy, thoracolumbar region 20151001 22991231 M5416 Radiculopathy, lumbar region 20151001 22991231 M5417 Radiculopathy, lumbosacral region 20151001 22991231 M542 Cervicalgia 20151001 22991231 M5431 Sciatica, right side 20151001 22991231 M5432 Sciatica, left side 20151001 22991231 M5441 Lumbago with sciatica, right side 20151001 22991231 M5442 Lumbago with sciatica, left side 20151001 22991231 M545 Low back pain 20151001 22991231 M546 Pain in thoracic spine 20151001 22991231 M5481 Occipital neuralgia 20151001 22991231
267 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M5489 Other dorsalgia 20151001 22991231 M549 Dorsalgia, unspecified 20151001 22991231 M62830 Muscle spasm of back 20151001 22991231 M6788 Other specified disorders of synovium and tendon, other site 20151001 22991231 M961 Postlaminectomy syndrome, not elsewhere classified 20151001 22991231 M9920 Subluxation stenosis of neural canal of head region 20151001 22991231 M9921 Subluxation stenosis of neural canal of cervical region 20151001 22991231 M9922 Subluxation stenosis of neural canal of thoracic region 20151001 22991231 M9923 Subluxation stenosis of neural canal of lumbar region 20151001 22991231 M9924 Subluxation stenosis of neural canal of sacral region 20151001 22991231 M9925 Subluxation stenosis of neural canal of pelvic region 20151001 22991231 M9926 Subluxation stenosis of neural canal of lower extremity 20151001 22991231 M9927 Subluxation stenosis of neural canal of upper extremity 20151001 22991231 M9928 Subluxation stenosis of neural canal of rib cage 20151001 22991231 M9929 Sublux stenosis of neural canal of abdomen and oth regions 20151001 22991231 M9930 Osseous stenosis of neural canal of head region 20151001 22991231 M9931 Osseous stenosis of neural canal of cervical region 20151001 22991231 M9932 Osseous stenosis of neural canal of thoracic region 20151001 22991231 M9933 Osseous stenosis of neural canal of lumbar region 20151001 22991231 M9934 Osseous stenosis of neural canal of sacral region 20151001 22991231 M9935 Osseous stenosis of neural canal of pelvic region 20151001 22991231 M9936 Osseous stenosis of neural canal of lower extremity 20151001 22991231 M9937 Osseous stenosis of neural canal of upper extremity 20151001 22991231 M9938 Osseous stenosis of neural canal of rib cage 20151001 22991231 M9939 Osseous stenosis of neural canal of abdomen and oth regions 20151001 22991231 M9940 Connective tissue stenosis of neural canal of head region 20151001 22991231 M9941 Connective tiss stenosis of neural canal of cervical region 20151001 22991231 M9942 Connective tiss stenosis of neural canal of thoracic region 20151001 22991231 M9943 Connective tissue stenosis of neural canal of lumbar region 20151001 22991231 M9944 Connective tissue stenosis of neural canal of sacral region 20151001 22991231 M9945 Connective tissue stenosis of neural canal of pelvic region 20151001 22991231
268 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M9946 Connective tiss stenosis of neural canal of lower extremity 20151001 22991231 M9947 Connective tiss stenosis of neural canal of upper extremity 20151001 22991231 M9948 Connective tissue stenosis of neural canal of rib cage 20151001 22991231 M9949 Conn tiss stenos of neural canal of abdomen and oth regions 20151001 22991231 M9950 Intervertebral disc stenosis of neural canal of head region 20151001 22991231 M9951 Intvrt disc stenosis of neural canal of cervical region 20151001 22991231 M9952 Intvrt disc stenosis of neural canal of thoracic region 20151001 22991231 M9953 Intvrt disc stenosis of neural canal of lumbar region 20151001 22991231 M9954 Intvrt disc stenosis of neural canal of sacral region 20151001 22991231 M9955 Intvrt disc stenosis of neural canal of pelvic region 20151001 22991231 M9956 Intervertebral disc stenosis of neural canal of low extrm 20151001 22991231 M9957 Intervertebral disc stenosis of neural canal of up extrem 20151001 22991231 M9958 Intervertebral disc stenosis of neural canal of rib cage 20151001 22991231 M9959 Intvrt disc stenos of neural canal of abd and oth regions 20151001 22991231 M9960 Osseous and sublux stenosis of intvrt foramin of head region 20151001 22991231 M9961 Osseous and sublux stenosis of intvrt foramin of cerv region 20151001 22991231 M9962 Osseous and sublux stenos of intvrt foramin of thor region 20151001 22991231 M9963 Osseous and sublux stenos of intvrt foramin of lumbar region 20151001 22991231 M9964 Osseous and sublux stenos of intvrt foramin of sacral region 20151001 22991231 M9965 Osseous and sublux stenos of intvrt foramin of pelvic region 20151001 22991231 M9966 Osseous and sublux stenosis of intvrt foramina of low extrm 20151001 22991231 M9967 Osseous and sublux stenosis of intvrt foramina of up extrem 20151001 22991231 M9968 Osseous and sublux stenosis of intvrt foramina of rib cage 20151001 22991231 M9969 Osseous & sublux stenos of intvrt foramin of abd and oth rgn 20151001 22991231 M9970 Conn tiss and disc stenosis of intvrt foramin of head region 20151001 22991231 M9971 Conn tiss and disc stenosis of intvrt foramin of cerv region 20151001 22991231 M9972 Conn tiss and disc stenos of intvrt foramin of thor region 20151001 22991231 M9973 Conn tiss and disc stenos of intvrt foramin of lumbar region 20151001 22991231 M9974 Conn tiss and disc stenos of intvrt foramin of sacral region 20151001 22991231 M9975 Conn tiss and disc stenos of intvrt foramin of pelvic region 20151001 22991231 M9976 Conn tiss and disc stenosis of intvrt foramina of low extrm 20151001 22991231
269 Table Diagnosis Codes for Physical Therapy, 15 Occupational Therapy and Speech Pathology Treatment Services ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes M9977 Conn tiss and disc stenosis of intvrt foramina of up extrem 20151001 22991231 M9978 Conn tiss and disc stenosis of intvrt foramina of rib cage 20151001 22991231 M9979 Conn tiss & disc stenos of intvrt foramin of abd and oth rgn 20151001 22991231 R451 Restlessness and agitation 20151001 22991231 R480 Dyslexia and alexia 20151001 22991231 R620 Delayed milestone in childhood 20151001 22991231 R6251 Failure to thrive (child) 20151001 22991231 R6252 Short stature (child) 20151001 22991231 R6259 Oth lack of expected normal physiol development in childhood 20151001 22991231 R627 Adult failure to thrive 20151001 22991231 R630 Anorexia 20151001 22991231 R631 Polydipsia 20151001 22991231 R632 Polyphagia 20151001 22991231 R633 Feeding difficulties 20151001 22991231 R634 Abnormal weight loss 20151001 22991231 R635 Abnormal weight gain 20151001 22991231 R636 Underweight 20151001 22991231
Table Listing, Previous Table 15, Next Table 17, End of Document
Table 16: Contains the diagnosis codes specified in policy transmittal 2015-102 pertaining to procedure code V2025 eyeglasses deluxe frames. Effective 2/1/2016: one of the listed diagnosis codes is required when V2025 is billed:
Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F445 Conversion disorder with seizures or convulsions 10/1/2016 12/31/2299
270 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes G40001 Local-rel idio epi w seiz of loc onst, not ntrct, w stat epi 10/1/2016 12/31/2299 G40009 Local-rel idio epi w seiz of loc onst,not ntrct,w/o stat epi 10/1/2016 12/31/2299 G40011 Local-rel idio epi w seiz of loc onset, ntrct, w stat epi 10/1/2016 12/31/2299 G40019 Local-rel idio epi w seiz of loc onset, ntrct, w/o stat epi 10/1/2016 12/31/2299 G40101 Local-rel symptc epi w simp part seiz, not ntrct, w stat epi 10/1/2016 12/31/2299 G40109 Local-rel symptc epi w simp prt seiz,not ntrct, w/o stat epi 10/1/2016 12/31/2299 G40111 Local-rel symptc epi w simple part seiz, ntrct, w stat epi 10/1/2016 12/31/2299 G40119 Local-rel symptc epi w simple part seiz, ntrct, w/o stat epi 10/1/2016 12/31/2299 G40201 Local-rel symptc epi w cmplx prt seiz, not ntrct, w stat epi 10/1/2016 12/31/2299 G40209 Local-rel symptc epi w cmplx prt seiz,not ntrct,w/o stat epi 10/1/2016 12/31/2299 G40211 Local-rel symptc epi w cmplx partial seiz, ntrct, w stat epi 10/1/2016 12/31/2299 G40219 Local-rel symptc epi w cmplx part seiz, ntrct, w/o stat epi 10/1/2016 12/31/2299 G40301 Gen idiopathic epilepsy, not intractable, w stat epi 10/1/2016 12/31/2299 G40309 Gen idiopathic epilepsy, not intractable, w/o stat epi 10/1/2016 12/31/2299 G40311 Generalized idiopathic epilepsy, intractable, w stat epi 10/1/2016 12/31/2299 G40319 Generalized idiopathic epilepsy, intractable, w/o stat epi 10/1/2016 12/31/2299 G40401 Oth generalized epilepsy, not intractable, w stat epi 10/1/2016 12/31/2299 G40409 Oth generalized epilepsy, not intractable, w/o stat epi 10/1/2016 12/31/2299 G40411 Oth generalized epilepsy, intractable, w status epilepticus 10/1/2016 12/31/2299 G40419 Oth generalized epilepsy, intractable, w/o stat epi 10/1/2016 12/31/2299 G40501 Epileptic seiz rel to extrn causes, not ntrct, w stat epi 10/1/2016 12/31/2299 G40509 Epileptic seiz rel to extrn causes, not ntrct, w/o stat epi 10/1/2016 12/31/2299 G40801 Other epilepsy, not intractable, with status epilepticus 10/1/2016 12/31/2299 G40802 Other epilepsy, not intractable, without status epilepticus 10/1/2016 12/31/2299 G40803 Other epilepsy, intractable, with status epilepticus 10/1/2016 12/31/2299 G40804 Other epilepsy, intractable, without status epilepticus 10/1/2016 12/31/2299 G40811 Lennox-Gastaut syndrome, not intractable, w stat epi 10/1/2016 12/31/2299 G40812 Lennox-Gastaut syndrome, not intractable, w/o stat epi 10/1/2016 12/31/2299 G40813 Lennox-Gastaut syndrome, intractable, w status epilepticus 10/1/2016 12/31/2299 G40814 Lennox-Gastaut syndrome, intractable, w/o status epilepticus 10/1/2016 12/31/2299 G40821 Epileptic spasms, not intractable, with status epilepticus 10/1/2016 12/31/2299
271 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes G40822 Epileptic spasms, not intractable, w/o status epilepticus 10/1/2016 12/31/2299 G40823 Epileptic spasms, intractable, with status epilepticus 10/1/2016 12/31/2299 G40824 Epileptic spasms, intractable, without status epilepticus 10/1/2016 12/31/2299 G4089 Other seizures 10/1/2016 12/31/2299 G40901 Epilepsy, unsp, not intractable, with status epilepticus 10/1/2016 12/31/2299 G40909 Epilepsy, unsp, not intractable, without status epilepticus 10/1/2016 12/31/2299 G40911 Epilepsy, unspecified, intractable, with status epilepticus 10/1/2016 12/31/2299 G40919 Epilepsy, unsp, intractable, without status epilepticus 10/1/2016 12/31/2299 G910 Communicating hydrocephalus 10/1/2016 12/31/2299 G911 Obstructive hydrocephalus 10/1/2016 12/31/2299 G912 (Idiopathic) normal pressure hydrocephalus 10/1/2016 12/31/2299 G913 Post-traumatic hydrocephalus, unspecified 10/1/2016 12/31/2299 G914 Hydrocephalus in diseases classified elsewhere 10/1/2016 12/31/2299 H5503 Visual deprivation nystagmus 1/1/2016 12/31/2299 L230 Allergic contact dermatitis due to metals 2/1/2016 12/31/2299 L2481 Irritant contact dermatitis due to metals 2/1/2016 12/31/2299 M950 Acquired deformity of nose 10/1/2016 12/31/2299 M9510 Cauliflower ear, unspecified ear 10/1/2016 12/31/2299 M9511 Cauliflower ear, right ear 10/1/2016 12/31/2299 M9512 Cauliflower ear, left ear 10/1/2016 12/31/2299 M952 Other acquired deformity of head 10/1/2016 12/31/2299 Q010 Frontal encephalocele 10/1/2016 12/31/2299 Q011 Nasofrontal encephalocele 10/1/2016 12/31/2299 Q012 Occipital encephalocele 10/1/2016 12/31/2299 Q018 Encephalocele of other sites 10/1/2016 12/31/2299 Q019 Encephalocele, unspecified 10/1/2016 12/31/2299 Q02 Microcephaly 10/1/2016 12/31/2299 Q030 Malformations of aqueduct of Sylvius 10/1/2016 12/31/2299 Q031 Atresia of foramina of Magendie and Luschka 10/1/2016 12/31/2299 Q038 Other congenital hydrocephalus 10/1/2016 12/31/2299 Q039 Congenital hydrocephalus, unspecified 10/1/2016 12/31/2299
272 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes Q040 Congenital malformations of corpus callosum 10/1/2016 12/31/2299 Q041 Arhinencephaly 10/1/2016 12/31/2299 Q042 Holoprosencephaly 10/1/2016 12/31/2299 Q043 Other reduction deformities of brain 10/1/2016 12/31/2299 Q044 Septo-optic dysplasia of brain 10/1/2016 12/31/2299 Q045 Megalencephaly 10/1/2016 12/31/2299 Q046 Congenital cerebral cysts 10/1/2016 12/31/2299 Q048 Other specified congenital malformations of brain 10/1/2016 12/31/2299 Q049 Congenital malformation of brain, unspecified 10/1/2016 12/31/2299 Q050 Cervical spina bifida with hydrocephalus 10/1/2016 12/31/2299 Q051 Thoracic spina bifida with hydrocephalus 10/1/2016 12/31/2299 Q052 Lumbar spina bifida with hydrocephalus 10/1/2016 12/31/2299 Q053 Sacral spina bifida with hydrocephalus 10/1/2016 12/31/2299 Q054 Unspecified spina bifida with hydrocephalus 10/1/2016 12/31/2299 Q0702 Arnold-Chiari syndrome with hydrocephalus 10/1/2016 12/31/2299 Q0703 Arnold-Chiari syndrome with spina bifida and hydrocephalus 10/1/2016 12/31/2299 Q078 Other specified congenital malformations of nervous system 10/1/2016 12/31/2299 Q079 Congenital malformation of nervous system, unspecified 10/1/2016 12/31/2299 Q150 Congenital glaucoma 1/1/2016 12/31/2299 Q160 Congenital absence of (ear) auricle 10/1/2016 12/31/2299 Q169 Congen malform of ear causing impairment of hearing, unsp 10/1/2016 12/31/2299 Q170 Accessory auricle 10/1/2016 12/31/2299 Q171 Macrotia 10/1/2016 12/31/2299 Q172 Microtia 10/1/2016 12/31/2299 Q173 Other misshapen ear 10/1/2016 12/31/2299 Q174 Misplaced ear 10/1/2016 12/31/2299 Q175 Prominent ear 10/1/2016 12/31/2299 Q178 Other specified congenital malformations of ear 10/1/2016 12/31/2299 Q179 Congenital malformation of ear, unspecified 10/1/2016 12/31/2299 Q301 Agenesis and underdevelopment of nose 10/1/2016 12/31/2299 Q308 Other congenital malformations of nose 10/1/2016 12/31/2299
273 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes Q309 Congenital malformation of nose, unspecified 10/1/2016 12/31/2299 Q670 Congenital facial asymmetry 10/1/2016 12/31/2299 Q671 Congenital compression facies 10/1/2016 12/31/2299 Q672 Dolichocephaly 10/1/2016 12/31/2299 Q673 Plagiocephaly 10/1/2016 12/31/2299 Q674 Other congenital deformities of skull, face and jaw 10/1/2016 12/31/2299 Q750 Craniosynostosis 10/1/2016 12/31/2299 Q751 Craniofacial dysostosis 10/1/2016 12/31/2299 Q752 Hypertelorism 10/1/2016 12/31/2299 Q753 Macrocephaly 10/1/2016 12/31/2299 Q754 Mandibulofacial dysostosis 10/1/2016 12/31/2299 Q755 Oculomandibular dysostosis 10/1/2016 12/31/2299 Q758 Oth congenital malformations of skull and face bones 10/1/2016 12/31/2299 Q759 Congenital malformation of skull and face bones, unspecified 10/1/2016 12/31/2299 Q860 Fetal alcohol syndrome (dysmorphic) 10/1/2016 12/31/2299 Q861 Fetal hydantoin syndrome 10/1/2016 12/31/2299 Q862 Dysmorphism due to warfarin 10/1/2016 12/31/2299 Q868 Oth congen malform syndromes due to known exogenous causes 10/1/2016 12/31/2299 Q870 Congen malform syndromes predom affecting facial appearance 10/1/2016 12/31/2299 Q871 Congenital malform syndromes predom assoc w short stature 10/1/2016 09/30/2019 Q8711 Prader-Willi syndrome 10/1/2019 12/31/2299 Q8719 Other congen malform synd predom assoc with short stature 10/1/2019 12/31/2299 Q872 Congenital malformation syndromes predom involving limbs 10/1/2016 12/31/2299 Q873 Congenital malformation syndromes involving early overgrowth 10/1/2016 12/31/2299 Q8740 Marfan's syndrome, unspecified 10/1/2016 12/31/2299 Q87410 Marfan's syndrome with aortic dilation 10/1/2016 12/31/2299 Q87418 Marfan's syndrome with other cardiovascular manifestations 10/1/2016 12/31/2299 Q8742 Marfan's syndrome with ocular manifestations 10/1/2016 12/31/2299 Q8743 Marfan's syndrome with skeletal manifestation 10/1/2016 12/31/2299 Q875 Oth congenital malformation syndromes w oth skeletal changes 10/1/2016 12/31/2299 Q8781 Alport syndrome 10/1/2016 12/31/2299
274 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes Q8789 Oth congenital malformation syndromes, NEC 10/1/2016 12/31/2299 Q897 Multiple congenital malformations, not elsewhere classified 10/1/2016 12/31/2299 Q898 Other specified congenital malformations 10/1/2016 12/31/2299 Q899 Congenital malformation, unspecified 10/1/2016 12/31/2299 Q900 Trisomy 21, nonmosaicism (meiotic nondisjunction) 10/1/2016 12/31/2299 Q901 Trisomy 21, mosaicism (mitotic nondisjunction) 10/1/2016 12/31/2299 Q902 Trisomy 21, translocation 10/1/2016 12/31/2299 Q909 Down syndrome, unspecified 10/1/2016 12/31/2299 Q910 Trisomy 18, nonmosaicism (meiotic nondisjunction) 10/1/2016 12/31/2299 Q911 Trisomy 18, mosaicism (mitotic nondisjunction) 10/1/2016 12/31/2299 Q912 Trisomy 18, translocation 10/1/2016 12/31/2299 Q913 Trisomy 18, unspecified 10/1/2016 12/31/2299 Q914 Trisomy 13, nonmosaicism (meiotic nondisjunction) 10/1/2016 12/31/2299 Q915 Trisomy 13, mosaicism (mitotic nondisjunction) 10/1/2016 12/31/2299 Q916 Trisomy 13, translocation 10/1/2016 12/31/2299 Q917 Trisomy 13, unspecified 10/1/2016 12/31/2299 Q920 Whole chromosome trisomy, nonmosaic (meiotic nondisjunction) 10/1/2016 12/31/2299 Q921 Whole chromosome trisomy, mosaicism (mitotic nondisjunction) 10/1/2016 12/31/2299 Q922 Partial trisomy 10/1/2016 12/31/2299 Q925 Duplications with other complex rearrangements 10/1/2016 12/31/2299 Q9261 Marker chromosomes in normal individual 10/1/2016 12/31/2299 Q9262 Marker chromosomes in abnormal individual 10/1/2016 12/31/2299 Q927 Triploidy and polyploidy 10/1/2016 12/31/2299 Q928 Other specified trisomies and partial trisomies of autosomes 10/1/2016 12/31/2299 Q929 Trisomy and partial trisomy of autosomes, unspecified 10/1/2016 12/31/2299 Q930 Whole chromosome monosomy,nonmosaic (meiotic nondisjunction) 10/1/2016 12/31/2299 Q931 Whole chromosome monosomy, mosaic (mitotic nondisjunction) 10/1/2016 12/31/2299 Q932 Chromosome replaced with ring, dicentric or isochromosome 10/1/2016 12/31/2299 Q933 Deletion of short arm of chromosome 4 10/1/2016 12/31/2299 Q934 Deletion of short arm of chromosome 5 10/1/2016 12/31/2299 Q935 Other deletions of part of a chromosome 10/1/2016 12/31/2299
275 Diagnosis codes for procedure code V2025 eyeglasses deluxe frames Table specified in policy transmittal 2015-102. Effective 2/1/2016: one of the listed 16 diagnosis codes is required when V2025 is billed ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes Q937 Deletions with other complex rearrangements 10/1/2016 12/31/2299 Q9381 Velo-cardio-facial syndrome 10/1/2016 12/31/2299 Q9388 Other microdeletions 10/1/2016 12/31/2299 Q9389 Other deletions from the autosomes 10/1/2016 12/31/2299 Q939 Deletion from autosomes, unspecified 10/1/2016 12/31/2299 Q950 Balanced translocation and insertion in normal individual 10/1/2016 12/31/2299 Q951 Chromosome inversion in normal individual 10/1/2016 12/31/2299 Q952 Balanced autosomal rearrangement in abnormal individual 10/1/2016 12/31/2299 Q953 Balanced sex/autosomal rearrangement in abnormal individual 10/1/2016 12/31/2299 Q955 Individual with autosomal fragile site 10/1/2016 12/31/2299 Q958 Other balanced rearrangements and structural markers 10/1/2016 12/31/2299 Q959 Balanced rearrangement and structural marker, unspecified 10/1/2016 12/31/2299 Q960 Karyotype 45, X 10/1/2016 12/31/2299 Q961 Karyotype 46, X iso (Xq) 10/1/2016 12/31/2299 Q962 Karyotype 46, X w abnormal sex chromosome, except iso (Xq) 10/1/2016 12/31/2299 Q963 Mosaicism, 45, X/46, XX or XY 10/1/2016 12/31/2299 Q964 Mosaic, 45, X/other cell line(s) w abnormal sex chromosome 10/1/2016 12/31/2299 Q968 Other variants of Turner's syndrome 10/1/2016 12/31/2299 Q969 Turner's syndrome, unspecified 10/1/2016 12/31/2299 Q992 Fragile X chromosome 10/1/2016 12/31/2299 Q998 Other specified chromosome abnormalities 10/1/2016 12/31/2299 Q999 Chromosomal abnormality, unspecified 10/1/2016 12/31/2299 R561 Post traumatic seizures 10/1/2016 12/31/2299 R569 Unspecified convulsions 10/1/2016 12/31/2299 Z9009 Acquired absence of other part of head and neck 10/1/2016 12/31/2299
276 Table Listing, Previous Table 16, Next Table 18, End of Document
Table 17: Contains the list of ICD-10 diagnosis codes for DHMAS Targeted Case Management Services (2023T and T1017):
List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F0281 Dementia in oth diseases classd elswhr w behavioral disturb 20151001 22991231 F1011 Alcohol abuse, in remission 20171001 22991231 F10130 Alcohol abuse with withdrawal, uncomplicated 20201001 22991231 F10131 Alcohol abuse with withdrawal delirium 20201001 22991231 F10132 Alcohol abuse with withdrawal with perceptual disturbance 20201001 22991231 F10139 Alcohol abuse with withdrawal, unspecified 20201001 22991231 F1020 Alcohol dependence, uncomplicated 20151001 22991231 F1021 Alcohol dependence, in remission 20151001 22991231 F10220 Alcohol dependence with intoxication, uncomplicated 20151001 22991231 F10221 Alcohol dependence with intoxication delirium 20151001 22991231 F10230 Alcohol dependence with withdrawal, uncomplicated 20151001 22991231 F10231 Alcohol dependence with withdrawal delirium 20151001 22991231 F10232 Alcohol dependence w withdrawal with perceptual disturbance 20151001 22991231 F1024 Alcohol dependence with alcohol-induced mood disorder 20151001 22991231 F10250 Alcohol depend w alcoh-induce psychotic disorder w delusions 20151001 22991231 F10251 Alcohol depend w alcoh-induce psychotic disorder w hallucin 20151001 22991231 F1026 Alcohol depend w alcoh-induce persisting amnestic disorder 20151001 22991231 F1027 Alcohol dependence with alcohol-induced persisting dementia 20151001 22991231 F10280 Alcohol dependence with alcohol-induced anxiety disorder 20151001 22991231 F10281 Alcohol dependence with alcohol-induced sexual dysfunction 20151001 22991231 F10282 Alcohol dependence with alcohol-induced sleep disorder 20151001 22991231 F10288 Alcohol dependence with other alcohol-induced disorder 20151001 22991231 F10930 Alcohol use, unspecified with withdrawal, uncomplicated 20201001 22991231 F10931 Alcohol use, unspecified with withdrawal delirium 20201001 22991231 F10932 Alcohol use, unspecified with w/drawal w perceptual disturb 20201001 22991231 F10939 Alcohol use, unspecified with withdrawal, unspecified 20201001 22991231 F1111 Opioid abuse, in remission 20171001 22991231 F1113 Opioid abuse with withdrawal 20201001 22991231 F1120 Opioid dependence, uncomplicated 20151001 22991231 F1121 Opioid dependence, in remission 20151001 22991231 F11220 Opioid dependence with intoxication, uncomplicated 20151001 22991231 F11221 Opioid dependence with intoxication delirium 20151001 22991231 F11222 Opioid dependence w intoxication with perceptual disturbance 20151001 22991231 F1123 Opioid dependence with withdrawal 20151001 22991231 F1124 Opioid dependence with opioid-induced mood disorder 20151001 22991231 F11250 Opioid depend w opioid-induc psychotic disorder w delusions 20151001 22991231 F11251 Opioid depend w opioid-induc psychotic disorder w hallucin 20151001 22991231
277 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F11281 Opioid dependence with opioid-induced sexual dysfunction 20151001 22991231 F11282 Opioid dependence with opioid-induced sleep disorder 20151001 22991231 F11288 Opioid dependence with other opioid-induced disorder 20151001 22991231 F1211 Cannabis abuse, in remission 20171001 22991231 F1213 Cannabis abuse with withdrawal 20201001 22991231 F1220 Cannabis dependence, uncomplicated 20151001 22991231 F12220 Cannabis dependence with intoxication, uncomplicated 20151001 22991231 F12221 Cannabis dependence with intoxication delirium 20151001 22991231 F12222 Cannabis dependence w intoxication w perceptual disturbance 20151001 22991231 F1223 Cannabis dependence with withdrawal 20181001 22991231 F12250 Cannabis dependence with psychotic disorder with delusions 20151001 22991231 F12251 Cannabis dependence w psychotic disorder with hallucinations 20151001 22991231 F12280 Cannabis dependence with cannabis-induced anxiety disorder 20151001 22991231 F12288 Cannabis dependence with other cannabis-induced disorder 20151001 22991231 F1293 Cannabis use, unspecified with withdrawal 20181001 22991231 F1311 Sedative, hypnotic or anxiolytic abuse, in remission 20171001 22991231 F13130 Sedatv/hyp/anxiolytc abuse with withdrawal, uncomplicated 20201001 22991231 F13131 Sedatv/hyp/anxiolytc abuse with withdrawal delirium 20201001 22991231 F13132 Sedatv/hyp/anxiolytc abuse with w/drawal w perceptl disturb 20201001 22991231 F13139 Sedatv/hyp/anxiolytc abuse with withdrawal, unspecified 20201001 22991231 F1320 Sedative, hypnotic or anxiolytic dependence, uncomplicated 20151001 22991231 F1321 Sedative, hypnotic or anxiolytic dependence, in remission 20151001 22991231 F13220 Sedatv/hyp/anxiolytc dependence w intoxication, uncomp 20151001 22991231 F13221 Sedatv/hyp/anxiolytc dependence w intoxication delirium 20151001 22991231 F13230 Sedatv/hyp/anxiolytc dependence w withdrawal, uncomplicated 20151001 22991231 F13231 Sedatv/hyp/anxiolytc dependence w withdrawal delirium 20151001 22991231 F13232 Sedatv/hyp/anxiolytc depend w w/drawal w perceptual disturb 20151001 22991231 F1324 Sedative, hypnotic or anxiolytic dependence w mood disorder 20151001 22991231 F13250 Sedatv/hyp/anxiolytc depend w psychotic disorder w delusions 20151001 22991231 F13251 Sedatv/hyp/anxiolytc depend w psychotic disorder w hallucin 20151001 22991231 F1326 Sedatv/hyp/anxiolytc depend w persisting amnestic disorder 20151001 22991231 F1327 Sedatv/hyp/anxiolytc dependence w persisting dementia 20151001 22991231 F13280 Sedatv/hyp/anxiolytc dependence w anxiety disorder 20151001 22991231 F13281 Sedatv/hyp/anxiolytc dependence w sexual dysfunction 20151001 22991231 F13282 Sedative, hypnotic or anxiolytic dependence w sleep disorder 20151001 22991231 F13288 Sedative, hypnotic or anxiolytic dependence w oth disorder 20151001 22991231 F1411 Cocaine abuse, in remission 20171001 22991231 F1413 Cocaine abuse, unspecified with withdrawal 20201001 22991231 F1420 Cocaine dependence, uncomplicated 20151001 22991231 F1421 Cocaine dependence, in remission 20151001 22991231 F14220 Cocaine dependence with intoxication, uncomplicated 20151001 22991231 F14221 Cocaine dependence with intoxication delirium 20151001 22991231 F14222 Cocaine dependence w intoxication w perceptual disturbance 20151001 22991231
278 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1423 Cocaine dependence with withdrawal 20151001 22991231 F1424 Cocaine dependence with cocaine-induced mood disorder 20151001 22991231 F14250 Cocaine depend w cocaine-induc psych disorder w delusions 20151001 22991231 F14251 Cocaine depend w cocaine-induc psychotic disorder w hallucin 20151001 22991231 F14280 Cocaine dependence with cocaine-induced anxiety disorder 20151001 22991231 F14281 Cocaine dependence with cocaine-induced sexual dysfunction 20151001 22991231 F14282 Cocaine dependence with cocaine-induced sleep disorder 20151001 22991231 F14288 Cocaine dependence with other cocaine-induced disorder 20151001 22991231 F1493 Cocaine use, unspecified with withdrawal 20201001 22991231 F1511 Other stimulant abuse, in remission 20171001 22991231 F1513 Other stimulant abuse with withdrawal 20201001 22991231 F1520 Other stimulant dependence, uncomplicated 20151001 22991231 F1521 Other stimulant dependence, in remission 20151001 22991231 F15220 Other stimulant dependence with intoxication, uncomplicated 20151001 22991231 F15221 Other stimulant dependence with intoxication delirium 20151001 22991231 F15222 Oth stimulant dependence w intox w perceptual disturbance 20151001 22991231 F1523 Other stimulant dependence with withdrawal 20151001 22991231 F1524 Oth stimulant dependence w stimulant-induced mood disorder 20151001 22991231 F15250 Oth stim depend w stim-induce psych disorder w delusions 20151001 22991231 F15251 Oth stimulant depend w stim-induce psych disorder w hallucin 20151001 22991231 F15280 Oth stimulant dependence w stim-induce anxiety disorder 20151001 22991231 F15281 Oth stimulant dependence w stim-induce sexual dysfunction 20151001 22991231 F15282 Oth stimulant dependence w stimulant-induced sleep disorder 20151001 22991231 F15288 Oth stimulant dependence with oth stimulant-induced disorder 20151001 22991231 F1611 Hallucinogen abuse, in remission 20171001 22991231 F1620 Hallucinogen dependence, uncomplicated 20151001 22991231 F1621 Hallucinogen dependence, in remission 20151001 22991231 F16220 Hallucinogen dependence with intoxication, uncomplicated 20151001 22991231 F16221 Hallucinogen dependence with intoxication with delirium 20151001 22991231 F1624 Hallucinogen dependence w hallucinogen-induced mood disorder 20151001 22991231 F16250 Hallucinogen dependence w psychotic disorder w delusions 20151001 22991231 F16251 Hallucinogen dependence w psychotic disorder w hallucin 20151001 22991231 F16280 Hallucinogen dependence w anxiety disorder 20151001 22991231 F16283 Hallucign depend w hallucign persisting perception disorder 20151001 22991231 F16288 Hallucinogen dependence w oth hallucinogen-induced disorder 20151001 22991231 F1811 Inhalant abuse, in remission 20171001 22991231 F1820 Inhalant dependence, uncomplicated 20151001 22991231 F1821 Inhalant dependence, in remission 20151001 22991231 F18220 Inhalant dependence with intoxication, uncomplicated 20151001 22991231 F18221 Inhalant dependence with intoxication delirium 20151001 22991231 F1824 Inhalant dependence with inhalant-induced mood disorder 20151001 22991231 F18250 Inhalant depend w inhalnt-induce psych disorder w delusions 20151001 22991231 F18251 Inhalant depend w inhalnt-induce psych disorder w hallucin 20151001 22991231
279 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F1827 Inhalant dependence with inhalant-induced dementia 20151001 22991231 F18280 Inhalant dependence with inhalant-induced anxiety disorder 20151001 22991231 F18288 Inhalant dependence with other inhalant-induced disorder 20151001 22991231 F1911 Other psychoactive substance abuse, in remission 20171001 22991231 F19130 Other psychoactive substance abuse with withdrawal, uncomp 20201001 22991231 F19131 Other psychoactive substance abuse with withdrawal delirium 20201001 22991231 F19132 Other psychoactv sub abuse with w/drawal w perceptl disturb 20201001 22991231 F19139 Other psychoactv substance abuse with withdrawal, unsp 20201001 22991231 F1920 Other psychoactive substance dependence, uncomplicated 20151001 22991231 F1921 Other psychoactive substance dependence, in remission 20151001 22991231 F19220 Oth psychoactive substance dependence w intoxication, uncomp 20151001 22991231 F19221 Oth psychoactive substance dependence w intox delirium 20151001 22991231 F19222 Oth psychoactv substance depend w intox w perceptual disturb 20151001 22991231 F19230 Oth psychoactive substance dependence w withdrawal, uncomp 20151001 22991231 F19231 Oth psychoactive substance dependence w withdrawal delirium 20151001 22991231 F19232 Oth psychoactv sub depend w w/drawal w perceptl disturb 20151001 22991231 F1924 Oth psychoactive substance dependence w mood disorder 20151001 22991231 F19250 Oth psychoactv substance depend w psych disorder w delusions 20151001 22991231 F19251 Oth psychoactv substance depend w psych disorder w hallucin 20151001 22991231 F1926 Oth psychoactv substance depend w persist amnestic disorder 20151001 22991231 F1927 Oth psychoactive substance dependence w persisting dementia 20151001 22991231 F19280 Oth psychoactive substance dependence w anxiety disorder 20151001 22991231 F19281 Oth psychoactive substance dependence w sexual dysfunction 20151001 22991231 F19282 Oth psychoactive substance dependence w sleep disorder 20151001 22991231 F19288 Oth psychoactive substance dependence w oth disorder 20151001 22991231 F200 Paranoid schizophrenia 20151001 22991231 F201 Disorganized schizophrenia 20151001 22991231 F202 Catatonic schizophrenia 20151001 22991231 F203 Undifferentiated schizophrenia 20151001 22991231 F205 Residual schizophrenia 20151001 22991231 F2081 Schizophreniform disorder 20151001 22991231 F2089 Other schizophrenia 20151001 22991231 F209 Schizophrenia, unspecified 20151001 22991231 F21 Schizotypal disorder 20151001 22991231 F22 Delusional disorders 20151001 22991231 F250 Schizoaffective disorder, bipolar type 20151001 22991231 F251 Schizoaffective disorder, depressive type 20151001 22991231 F258 Other schizoaffective disorders 20151001 22991231 F28 Oth psych disorder not due to a sub or known physiol cond 20151001 22991231 F3010 Manic episode without psychotic symptoms, unspecified 20151001 22991231 F3011 Manic episode without psychotic symptoms, mild 20151001 22991231 F3012 Manic episode without psychotic symptoms, moderate 20151001 22991231 F3013 Manic episode, severe, without psychotic symptoms 20151001 22991231
280 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F302 Manic episode, severe with psychotic symptoms 20151001 22991231 F303 Manic episode in partial remission 20151001 22991231 F304 Manic episode in full remission 20151001 22991231 F308 Other manic episodes 20151001 22991231 F310 Bipolar disorder, current episode hypomanic 20151001 22991231 F3111 Bipolar disord, crnt episode manic w/o psych features, mild 20151001 22991231 F3112 Bipolar disord, crnt episode manic w/o psych features, mod 20151001 22991231 F3113 Bipolar disord, crnt epsd manic w/o psych features, severe 20151001 22991231 F312 Bipolar disord, crnt episode manic severe w psych features 20151001 22991231 F3131 Bipolar disorder, current episode depressed, mild 20151001 22991231 F3132 Bipolar disorder, current episode depressed, moderate 20151001 22991231 F314 Bipolar disord, crnt epsd depress, sev, w/o psych features 20151001 22991231 F315 Bipolar disord, crnt epsd depress, severe, w psych features 20151001 22991231 F3161 Bipolar disorder, current episode mixed, mild 20151001 22991231 F3162 Bipolar disorder, current episode mixed, moderate 20151001 22991231 F3163 Bipolar disord, crnt epsd mixed, severe, w/o psych features 20151001 22991231 F3164 Bipolar disord, crnt episode mixed, severe, w psych features 20151001 22991231 F3171 Bipolar disord, in partial remis, most recent epsd hypomanic 20151001 22991231 F3172 Bipolar disord, in full remis, most recent episode hypomanic 20151001 22991231 F3173 Bipolar disord, in partial remis, most recent episode manic 20151001 22991231 F3174 Bipolar disorder, in full remis, most recent episode manic 20151001 22991231 F3175 Bipolar disord, in partial remis, most recent epsd depress 20151001 22991231 F3176 Bipolar disorder, in full remis, most recent episode depress 20151001 22991231 F3177 Bipolar disord, in partial remis, most recent episode mixed 20151001 22991231 F3178 Bipolar disorder, in full remis, most recent episode mixed 20151001 22991231 F3181 Bipolar II disorder 20151001 22991231 F3189 Other bipolar disorder 20151001 22991231 F320 Major depressive disorder, single episode, mild 20151001 22991231 F321 Major depressive disorder, single episode, moderate 20151001 22991231 F322 Major depressv disord, single epsd, sev w/o psych features 20151001 22991231 F323 Major depressv disord, single epsd, severe w psych features 20151001 22991231 F324 Major depressv disorder, single episode, in partial remis 20151001 22991231 F325 Major depressive disorder, single episode, in full remission 20151001 22991231 F328 Other depressive episodes 20151001 20160930 F3289 Other specified depressive episodes 20161001 22991231 F330 Major depressive disorder, recurrent, mild 20151001 22991231 F331 Major depressive disorder, recurrent, moderate 20151001 22991231 F332 Major depressv disorder, recurrent severe w/o psych features 20151001 22991231 F333 Major depressv disorder, recurrent, severe w psych symptoms 20151001 22991231 F3340 Major depressive disorder, recurrent, in remission, unsp 20151001 22991231 F3341 Major depressive disorder, recurrent, in partial remission 20151001 22991231 F3342 Major depressive disorder, recurrent, in full remission 20151001 22991231 F338 Other recurrent depressive disorders 20151001 22991231
281 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F339 Major depressive disorder, recurrent, unspecified 20151001 22991231 F340 Cyclothymic disorder 20151001 22991231 F341 Dysthymic disorder 20151001 22991231 F348 Other persistent mood [affective] disorders 20151001 20160930 F3481 Disruptive mood dysregulation disorder 20161001 22991231 F3489 Other specified persistent mood disorders 20161001 22991231 F4001 Agoraphobia with panic disorder 20151001 22991231 F4002 Agoraphobia without panic disorder 20151001 22991231 F4011 Social phobia, generalized 20151001 22991231 F410 Panic disorder [episodic paroxysmal anxiety] 20151001 22991231 F411 Generalized anxiety disorder 20151001 22991231 F413 Other mixed anxiety disorders 20151001 22991231 F418 Other specified anxiety disorders 20151001 22991231 F42 Obsessive-compulsive disorder 20151001 20160930 F422 Mixed obsessional thoughts and acts 20161001 22991231 F423 Hoarding disorder 20161001 22991231 F428 Other obsessive-compulsive disorder 20161001 22991231 F4311 Post-traumatic stress disorder, acute 20151001 22991231 F4312 Post-traumatic stress disorder, chronic 20151001 22991231 F440 Dissociative amnesia 20151001 22991231 F441 Dissociative fugue 20151001 22991231 F442 Dissociative stupor 20151001 22991231 F444 Conversion disorder with motor symptom or deficit 20151001 22991231 F445 Conversion disorder with seizures or convulsions 20151001 22991231 F446 Conversion disorder with sensory symptom or deficit 20151001 22991231 F447 Conversion disorder with mixed symptom presentation 20151001 22991231 F4481 Dissociative identity disorder 20151001 22991231 F4489 Other dissociative and conversion disorders 20151001 22991231 F5001 Anorexia nervosa, restricting type 20151001 22991231 F5002 Anorexia nervosa, binge eating/purging type 20151001 22991231 F502 Bulimia nervosa 20151001 22991231 F508 Other eating disorders 20151001 20160930 F5081 Binge eating disorder 20161001 22991231 F5082 Avoidant/restrictive food intake disorder 20171001 22991231 F5089 Other specified eating disorder 20161001 22991231 F53 Puerperal psychosis 20151001 20180930 F530 Postpartum depression 20181001 22991231 F531 Puerperal psychosis 20181001 22991231 F600 Paranoid personality disorder 20151001 22991231 F601 Schizoid personality disorder 20151001 22991231 F602 Antisocial personality disorder 20151001 22991231 F603 Borderline personality disorder 20151001 22991231 F605 Obsessive-compulsive personality disorder 20151001 22991231
282 List of ICD-10 diagnosis codes for DHMAS Targeted Case Management Table 17 Services (2023T and T1017) ICD-10- ICD-10-CM descriptions Effective End Date CM Date codes F630 Pathological gambling 20151001 22991231 F631 Pyromania 20151001 22991231 F6381 Intermittent explosive disorder 20151001 22991231 F650 Fetishism 20151001 22991231 F651 Transvestic fetishism 20151001 22991231 F652 Exhibitionism 20151001 22991231 F653 Voyeurism 20151001 22991231 F654 Pedophilia 20151001 22991231 F6551 Sexual masochism 20151001 22991231 F6552 Sexual sadism 20151001 22991231 F6581 Frotteurism 20151001 22991231 F6589 Other paraphilias 20151001 22991231 F6811 Factit disord imposed on self, with predom psych signs/symp 20151001 22991231 F6813 Factit disord impsd on self,w comb psych & physcl signs/symp 20151001 22991231 F68A Factitious disorder imposed on another 20181001 22991231 T1491XA Suicide attempt, initial encounter 20171001 22991231 T1491XD Suicide attempt, subsequent encounter 20171001 22991231 T1491XS Suicide attempt, sequela 20171001 22991231
Table Listing, Previous Table 17, Next Table 19, End of Document
Table 18: Contains the Gender Reassignment Procedure and Surgery Pricing List:
Table 18 Codes for Gender Reassignment Procedure and Surgery Pricing List
The following list should be used when pricing prior authorizations (PA) for gender affirmation professional surgical services and procedures under HUSKY A, B, C and D.* Diagnosis code F64.0-Transsexualism must be on all submitted PA requests and claims. Code Description Professional Rate Effective End date Range (proposed Date rate) Chemical peel facial epidermal (by 15788 $150 - $350 10/1/2018 12/31/2299 aesthetician)
283
Table 18 Codes for Gender Reassignment Procedure and Surgery Pricing List
The following list should be used when pricing prior authorizations (PA) for gender affirmation professional surgical services and procedures under HUSKY A, B, C and D.* Diagnosis code F64.0-Transsexualism must be on all submitted PA requests and claims. Code Description Professional Rate Effective End date Range (proposed Date rate) Chemical peel facial dermal (phenol, 15789 $3,500 10/1/2018 12/31/2299 etc) Excision excess skin/sub tissue: hip 15834 $9,000 - $11,000 10/1/2018 12/31/2299 bilateral Excision excess skin/sub tissue: 15835 $7,000 10/1/2018 12/31/2299 buttock, bilateral Excision excess skin/sub tissue: 15836 $7,500 10/1/2018 12/31/2299 arm, bilateral Excision excess skin/sub tissue: 15839 $3,500 - $7,200 10/1/2018 12/31/2299 abdomen 15876 Liposuction neck $1,500 10/1/2018 12/31/2299 15877 Lipo trunk lower abdomen only $2,000 10/1/2018 12/31/2299 15877 Lipo trunk upper and lower abdomen $3,500 10/1/2018 12/31/2299 15878 Lipo upper extremity, bilateral $3,000 10/1/2018 12/31/2299 Lipo lower extremity, inner thigh 15879 $2,000 10/1/2018 12/31/2299 bilateral 15879 Lipo calves bilateral $4,000 10/1/2018 12/31/2299 15879 Lipo Ankles bilateral $1,500 10/1/2018 12/31/2299 17999 Laser hair removal of facial hair $377.73 4/1/2019 12/31/2299 19304 Mastectomy, subcutaneous $4,500 - $7,500 10/1/2018 12/31/2299 19316 Mastopexy $4,500 - $7,500 10/1/2018 12/31/2299 19325 Placement of permanent implant $6,500 10/1/2018 12/31/2299 19350 Nipple Areola reconstruction $3,500 - $5,500 10/1/2018 12/31/2299 Breast reconstruction w/tissue 19357 expander and expansion. Insertion $4,500 - $8,500 10/1/2018 12/31/2299 of implant 21120 Genioplasty $3,500 10/1/2018 12/31/2299
284
Table 18 Codes for Gender Reassignment Procedure and Surgery Pricing List
The following list should be used when pricing prior authorizations (PA) for gender affirmation professional surgical services and procedures under HUSKY A, B, C and D.* Diagnosis code F64.0-Transsexualism must be on all submitted PA requests and claims. Code Description Professional Rate Effective End date Range (proposed Date rate)
21121 Genioplasty sliding osteotomy $4,500 10/1/2018 12/31/2299 Augmentation mandibular prosthetic 21125 $3,000 10/1/2018 12/31/2299 material 21137 Reduction forehead contouring only $6,000 10/1/2018 12/31/2299 Osteoplasty facial bones 21208 $3,500 - $4,500 10/1/2018 12/31/2299 augmentation 21209 Osteoplasty facial reduction $3,500 - $4,500 10/1/2018 12/31/2299 21210 Graft, bone nasal, maxillary or malar $5,500 - $7,500 10/1/2018 12/31/2299 Graft; rib, autogenous to face chin 21230 $3,500 - $4,500 10/1/2018 12/31/2299 nose or ear 21235 Graft ear cartilage to nose or ear $4,500 - $6,500 10/1/2018 12/31/2299 Reconstruction of mandible or 21245 $3,000 10/1/2018 12/31/2299 maxilla w/ implant 30400 Rhinoplasty primary $5,500 10/1/2018 12/31/2299 30410 Rhino primary complete $5,500 10/1/2018 12/31/2299 30420 Rhino with septal repair $6,500 10/1/2018 12/31/2299 30430 Rhino secondary minor revision $3,000 10/1/2018 12/31/2299 Rhino secondary intermediate 30435 $4,500 10/1/2018 12/31/2299 revision 30450 Rhino secondary major revision $5,500 10/1/2018 12/31/2299 53430 Urethroplasty $4,500 10/1/2018 12/31/2299 54125 Amputation of penis $4,000 10/1/2018 12/31/2299 54161 Glansplasty $1,000 10/1/2018 12/31/2299 54520 Orchiectomy $1,500 10/1/2018 12/31/2299 54660 Insertion of Testicular Implants $1,500 10/1/2018 12/31/2299
285
Table 18 Codes for Gender Reassignment Procedure and Surgery Pricing List
The following list should be used when pricing prior authorizations (PA) for gender affirmation professional surgical services and procedures under HUSKY A, B, C and D.* Diagnosis code F64.0-Transsexualism must be on all submitted PA requests and claims. Code Description Professional Rate Effective End date Range (proposed Date rate)
55180 Scrotoplasty $3,000 10/1/2018 12/31/2299 56800 Plastic Repair of Introitus $2,500 - $5,500 10/1/2018 12/31/2299 56805 Metoidioplasty (clitoral release) $3,800 10/1/2018 12/31/2299 57106 Sub-total vaginectomy $4,500 10/1/2018 12/31/2299 Construction of artificial vagina w/o 57291 $3,500 - $5,500 10/1/2018 12/31/2299 graft Construction of artificial vagina 57292 $4,500 - $5,500 10/1/2018 12/31/2299 w/graft
67900 Repair brow ptosis $5,500 10/1/2018 12/31/2299 67904 repair blepharoptosis $3,500 10/1/2018 12/31/2299 69300 Otoplasty bilateral $5,500 10/1/2018 12/31/2299 Office Consultation (For laser hair 99243 $255 4/1/2019 12/31/2299 services only) For guidance and billing instructions for gender reassignment procedures and surgical codes, please refer to provider bulletins: PB 16-97, PB 17-17 and PB 19-19. * Please note that HUSKY members who are receiving gender affirmation professional services and/or procedures are also eligible to receive additional medical services not listed on this fee table. Fee schedules for additional medical services can be found on www.ctdssmap.com.
286 Table Listing, Previous Table 18, Next Table 20, End of Document
Table 19: Contains the Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations:
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Sterile water saline and/or dextrose diluent/flush 10 A4216 16 per month 7/1/2021 12/31/2299 ml A4217 Sterile water/saline 500 ml 16 per month 7/1/2021 12/31/2299 A4218 Sterile saline or water metered dose dispenser 10 ml 31 per month 7/1/2021 12/31/2299 Supplies for maintenance of non-insulin drug infusion A4221 20 per month 7/1/2021 12/31/2299 catheter per week (list dr Infusion supplies for external drug infusion pump per A4222 31 per month 7/1/2021 12/31/2299 cassette or bag (list drug Infusion supplies not used with external infusion A4223 40 per month 7/1/2021 12/31/2299 pump per cassette or bag (list Supplies for maintenance of insulin infusion catheter A4224 30 per month 7/1/2021 12/31/2299 per week Supplies for external insulin infusion pump syringe A4225 20 per month 7/1/2021 12/31/2299 type cartridge sterile each Infusion set for external insulin pump non needle A4230 31 per month 7/1/2021 12/31/2299 cannula type A4231 Infusion set for external insulin pump needle type 31 per month 7/1/2021 12/31/2299 Replacement battery alkaline (other than j cell) for A4233 2 per month 7/1/2021 12/31/2299 use with medically necessar Replacement battery alkaline j cell for use with A4234 2 per month 7/1/2021 12/31/2299 medically necessary home blood
287
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Replacement battery lithium for use with medically A4235 2 per month 7/1/2021 12/31/2299 necessary home blood glucose Replacement battery silver oxide for use with A4236 2 per month 7/1/2021 12/31/2299 medically necessary home blood glu A4244 Alcohol or peroxide per pint 4 per month 7/1/2021 12/31/2299 A4245 Alcohol wipes per box 2 per month 7/1/2021 12/31/2299 A4246 Betadine or phisohex solution per pint 4 per month 7/1/2021 12/31/2299 A4247 Betadine or iodine swabs/wipes per box 4 per month 7/1/2021 12/31/2299 Urine test or reagent strips or tablets (100 tablets or A4250 2 per month 7/1/2021 12/31/2299 strips) Blood glucose test or reagent strips for home blood A4253 4 per month 7/1/2021 12/31/2299 glucose monitor per 50 strip A4255 Platforms for home blood glucose monitor 50 per box 1 per month 7/1/2021 12/31/2299 A4256 Normal low and high calibrator solution / chips 2 per month 7/1/2021 12/31/2299 A4258 Spring-powered device for lancet each 1 per month 7/1/2021 12/31/2299 A4259 Lancets per box of 100 2 per month 7/1/2021 12/31/2299 A4265 Paraffin per pound 2 per month 7/1/2021 12/31/2299 A4267 Contraceptive supply condom male each 36 per month 7/1/2021 12/31/2299 A4268 Contraceptive supply condom female each 30 per month 7/1/2021 12/31/2299 A4269 Contraceptive supply spermicide (e.g. foam gel) each 1 per month 7/1/2021 12/31/2299 Adhesive skin support attachment for use with A4280 2 per month 7/1/2021 12/31/2299 external breast prosthesis each Disposable drug delivery system flow rate of 50 ml or A4305 15 per month 7/1/2021 12/31/2299 greater per hour Insertion tray without drainage bag and without A4310 4 per month 7/1/2021 12/31/2299 catheter (accessories only)
288
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Insertion tray without drainage bag with indwelling A4311 6 per month 7/1/2021 12/31/2299 catheter foley type two-way Insertion tray without drainage bag with indwelling A4312 6 per month 7/1/2021 12/31/2299 catheter foley type two-way Insertion tray without drainage bag with indwelling A4313 6 per month 7/1/2021 12/31/2299 catheter foley type three-wa Insertion tray with drainage bag with indwelling A4314 6 per month 7/1/2021 12/31/2299 catheter foley type two-way lat Insertion tray with drainage bag with indwelling A4315 6 per month 7/1/2021 12/31/2299 catheter foley type two-way all Insertion tray with drainage bag with indwelling A4316 6 per month 7/1/2021 12/31/2299 catheter foley type three-way f A4320 Irrigation tray with bulb or piston syringe any purpose 10 per month 7/1/2021 12/31/2299 A4322 Irrigation syringe bulb or piston each 16 per month 7/1/2021 12/31/2299 Male external catheter with integral collection A4326 16 per month 7/1/2021 12/31/2299 chamber any type each Female external urinary collection device; meatal cup A4327 4 per month 7/1/2021 12/31/2299 each A4328 Female external urinary collection device; pouch each 31 per month 7/1/2021 12/31/2299 A4330 Perianal fecal collection pouch with adhesive each 31 per month 7/1/2021 12/31/2299 Extension drainage tubing any type any length with A4331 4 per month 7/1/2021 12/31/2299 connector/adaptor for use wit Urinary catheter anchoring device adhesive skin A4333 4 per month 7/1/2021 12/31/2299 attachment each A4334 Urinary catheter anchoring device leg strap each 8 per month 7/1/2021 12/31/2299 Indwelling catheter; foley type two-way latex with A4338 6 per month 7/1/2021 12/31/2299 coating (teflon silicone sili
289
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Indwelling catheter; specialty type (e.g. coude A4340 6 per month 7/1/2021 12/31/2299 mushroom wing etc.) each Indwelling catheter foley type two-way all silicone A4344 6 per month 7/1/2021 12/31/2299 each Indwelling catheter; foley type three way for A4346 8 per month 7/1/2021 12/31/2299 continuous irrigation each Male external catheter with or without adhesive A4349 60 per month 7/1/2021 12/31/2299 disposable each Intermittent urinary catheter; straight tip with or A4351 200 per month 7/1/2021 12/31/2299 without coating (teflon sili Intermittent urinary catheter; coude (curved) tip with A4352 200 per month 7/1/2021 12/31/2299 or without coating (teflo A4353 Intermittent urinary catheter with insertion supplies 200 per month 7/1/2021 12/31/2299 A4354 Insertion tray with drainage bag but without catheter 4 per month 7/1/2021 12/31/2299 Irrigation tubing set for continuous bladder irrigation A4355 16 per month 7/1/2021 12/31/2299 through a three-way indw External urethral clamp or compression device (not to A4356 1 per month 7/1/2021 12/31/2299 be used for catheter clamp Bedside drainage bag day or night with or without A4357 8 per month 7/1/2021 12/31/2299 anti-reflux device with or wit Urinary drainage bag leg or abdomen vinyl with or A4358 16 per month 7/1/2021 12/31/2299 without tube with straps each Disposable external urethral clamp or compression A4360 31 per month 7/1/2021 12/31/2299 device with pad and/or pouch e A4361 Ostomy faceplate each 10 per month 7/1/2021 12/31/2299 A4362 Skin barrier; solid 4 x 4 or equivalent; each 31 per month 7/1/2021 12/31/2299 A4363 Ostomy clamp any type replacement only each 8 per month 7/1/2021 12/31/2299
290
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date A4364 Adhesive liquid or equal any type per oz 16 per month 7/1/2021 12/31/2299 A4366 Ostomy vent any type each 10 per month 7/1/2021 12/31/2299 A4367 Ostomy belt each 8 per month 7/1/2021 12/31/2299 A4368 Ostomy filter any type each 31 per month 7/1/2021 12/31/2299 A4369 Ostomy skin barrier liquid (spray brush etc.) per oz 16 per month 7/1/2021 12/31/2299 A4371 Ostomy skin barrier powder per oz 16 per month 7/1/2021 12/31/2299 Ostomy skin barrier solid 4 x 4 or equivalent standard A4372 16 per month 7/1/2021 12/31/2299 wear with built-in convex Ostomy skin barrier with flange (solid flexible or A4373 20 per month 7/1/2021 12/31/2299 accordion) with built-in conv Ostomy pouch drainable with faceplate attached A4375 20 per month 7/1/2021 12/31/2299 plastic each Ostomy pouch drainable with faceplate attached A4376 20 per month 7/1/2021 12/31/2299 rubber each Ostomy pouch drainable for use on faceplate plastic A4377 20 per month 7/1/2021 12/31/2299 each Ostomy pouch drainable for use on faceplate rubber A4378 20 per month 7/1/2021 12/31/2299 each Ostomy pouch urinary with faceplate attached plastic A4379 20 per month 7/1/2021 12/31/2299 each Ostomy pouch urinary with faceplate attached rubber A4380 20 per month 7/1/2021 12/31/2299 each Ostomy pouch urinary for use on faceplate plastic A4381 20 per month 7/1/2021 12/31/2299 each Ostomy pouch urinary for use on faceplate heavy A4382 20 per month 7/1/2021 12/31/2299 plastic each
291
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ostomy pouch urinary for use on faceplate rubber A4383 20 per month 7/1/2021 12/31/2299 each A4384 Ostomy faceplate equivalent silicone ring each 20 per month 7/1/2021 12/31/2299 Ostomy skin barrier solid 4 x 4 or equivalent extended A4385 31 per month 7/1/2021 12/31/2299 wear without built-in con Ostomy pouch closed with barrier attached with built- A4387 31 per month 7/1/2021 12/31/2299 in convexity (1 piece) each Ostomy pouch drainable with extended wear barrier A4388 31 per month 7/1/2021 12/31/2299 attached (1 piece) each Ostomy pouch drainable with barrier attached with A4389 31 per month 7/1/2021 12/31/2299 built-in convexity (1 piece) e Ostomy pouch drainable with extended wear barrier A4390 31 per month 7/1/2021 12/31/2299 attached with built-in convexi Ostomy pouch urinary with extended wear barrier A4391 20 per month 7/1/2021 12/31/2299 attached (1 piece) each Ostomy pouch urinary with standard wear barrier A4392 31 per month 7/1/2021 12/31/2299 attached with built-in convexity Ostomy pouch urinary with extended wear barrier A4393 31 per month 7/1/2021 12/31/2299 attached with built-in convexity Ostomy deodorant with or without lubricant for use in A4394 10 per month 7/1/2021 12/31/2299 ostomy pouch per fluid oun Ostomy deodorant for use in ostomy pouch solid per A4395 150 per month 7/1/2021 12/31/2299 tablet A4396 Ostomy belt with peristomal hernia support 2 per month 7/1/2021 12/31/2299 A4397 Irrigation supply; sleeve each 31 per month 7/1/2021 12/31/2299 A4398 Ostomy irrigation supply; bag each 31 per month 7/1/2021 12/31/2299
292
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ostomy irrigation supply; cone/catheter with or A4399 10 per month 7/1/2021 12/31/2299 without brush A4400 Ostomy irrigation set 2 per month 7/1/2021 12/31/2299 A4402 Lubricant per ounce 16 per month 7/1/2021 12/31/2299 A4404 Ostomy ring each 20 per month 7/1/2021 12/31/2299 Ostomy skin barrier non-pectin based paste per A4405 10 per month 7/1/2021 12/31/2299 ounce A4406 Ostomy skin barrier pectin-based paste per ounce 20 per month 7/1/2021 12/31/2299 Ostomy skin barrier with flange (solid flexible or A4407 20 per month 7/1/2021 12/31/2299 accordion) extended wear with Ostomy skin barrier with flange (solid flexible or A4408 20 per month 7/1/2021 12/31/2299 accordion) extended wear with Ostomy skin barrier with flange (solid flexible or A4409 20 per month 7/1/2021 12/31/2299 accordion) extended wear with Ostomy skin barrier with flange (solid flexible or A4410 20 per month 7/1/2021 12/31/2299 accordion) extended wear with Ostomy skin barrier solid 4 x 4 or equivalent extended A4411 20 per month 7/1/2021 12/31/2299 wear with built-in convex Ostomy pouch drainable high output for use on a A4412 20 per month 7/1/2021 12/31/2299 barrier with flange (2 piece sys Ostomy pouch drainable high output for use on a A4413 20 per month 7/1/2021 12/31/2299 barrier with flange (2 piece sys Ostomy skin barrier with flange (solid flexible or A4414 31 per month 7/1/2021 12/31/2299 accordion) without built-in c Ostomy skin barrier with flange (solid flexible or A4415 31 per month 7/1/2021 12/31/2299 accordion) without built-in c
293
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ostomy pouch closed with barrier attached with filter A4416 60 per month 7/1/2021 12/31/2299 (1 piece) each Ostomy pouch closed with barrier attached with built- A4417 60 per month 7/1/2021 12/31/2299 in convexity with filter (1 Ostomy pouch closed; without barrier attached with A4418 60 per month 7/1/2021 12/31/2299 filter (1 piece) each Ostomy pouch closed; for use on barrier with non- A4419 60 per month 7/1/2021 12/31/2299 locking flange with filter (2 p Ostomy pouch closed; for use on barrier with locking A4420 60 per month 7/1/2021 12/31/2299 flange (2 piece) each A4421 Ostomy supply; miscellaneous 1 per month 7/1/2021 12/31/2299 Ostomy absorbent material (sheet/pad/crystal packet) A4422 60 per month 7/1/2021 12/31/2299 for use in ostomy pouch to Ostomy pouch closed; for use on barrier with locking A4423 60 per month 7/1/2021 12/31/2299 flange with filter (2 piece Ostomy pouch drainable with barrier attached with A4424 20 per month 7/1/2021 12/31/2299 filter (1 piece) each Ostomy pouch drainable; for use on barrier with non- A4425 20 per month 7/1/2021 12/31/2299 locking flange with filter ( Ostomy pouch drainable; for use on barrier with A4426 20 per month 7/1/2021 12/31/2299 locking flange (2 piece system) Ostomy pouch drainable; for use on barrier with A4427 20 per month 7/1/2021 12/31/2299 locking flange with filter (2 pi Ostomy pouch urinary with extended wear barrier A4428 20 per month 7/1/2021 12/31/2299 attached with faucet-type tap wi Ostomy pouch urinary with barrier attached with built- A4429 20 per month 7/1/2021 12/31/2299 in convexity with faucet-t
294
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ostomy pouch urinary with extended wear barrier A4430 20 per month 7/1/2021 12/31/2299 attached with built-in convexity Ostomy pouch urinary; with barrier attached with A4431 20 per month 7/1/2021 12/31/2299 faucet-type tap with valve (1 p Ostomy pouch urinary; for use on barrier with non- A4432 20 per month 7/1/2021 12/31/2299 locking flange with faucet-typ Ostomy pouch urinary; for use on barrier with locking A4433 20 per month 7/1/2021 12/31/2299 flange (2 piece) each Ostomy pouch urinary; for use on barrier with locking A4434 20 per month 7/1/2021 12/31/2299 flange with faucet-type ta Ostomy pouch drainable high output with extended A4435 20 per month 7/1/2021 12/31/2299 wear barrier (one-piece system) A4450 Tape non-waterproof per 18 square inches 300 per month 7/1/2021 12/31/2299 A4452 Tape waterproof per 18 square inches 100 per month 7/1/2021 12/31/2299 Adhesive remover or solvent (for tape cement or A4455 16 per month 7/1/2021 12/31/2299 other adhesive) per ounce A4456 Adhesive remover wipes any type each 60 per month 7/1/2021 12/31/2299 Manual pump-operated enema system includes A4459 1 per 3 months 7/1/2021 12/31/2299 balloon catheter and all accessories A4461 Surgical dressing holder non-reusable each 8 per month 7/1/2021 12/31/2299 A4463 Surgical dressing holder reusable each 4 per month 7/1/2021 12/31/2299 A4465 Non-elastic binder for extremity 2 per month 7/1/2021 12/31/2299 A4481 Tracheostoma filter any type any size each 31 per month 7/1/2021 12/31/2299 A4556 Electrodes (e.g. apnea monitor) per pair 2 per month 7/1/2021 12/31/2299 2 twice per A4557 Lead wires (e.g. apnea monitor) per pair 7/1/2021 12/31/2299 year
295
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Conductive gel or paste for use with electrical device A4558 1 per month 7/1/2021 12/31/2299 (e.g. tens nmes) per oz Coupling gel or paste for use with ultrasound device A4559 16 per month 7/1/2021 12/31/2299 per oz A4561 Pessary rubber any type 1 per month 7/1/2021 12/31/2299 A4562 Pessary non rubber any type 1 per month 7/1/2021 12/31/2299 A4565 Slings 2 per month 7/1/2021 12/31/2299 Tubing with integrated heating element for use with cannot be combined with A4604 1 per 3 months 7/1/2021 12/31/2299 positive airway pressure dev A7037 A4605 Tracheal suction catheter closed system each 31 per month 7/1/2021 12/31/2299 Oxygen probe for use with oximeter device A4606 2 per month 7/1/2021 12/31/2299 replacement A4608 Transtracheal oxygen catheter each 2 per month 7/1/2021 12/31/2299 Battery heavy duty; replacement for patient owned A4611 1 per month 7/1/2021 12/31/2299 ventilator Battery cables; replacement for patient-owned A4612 1 per month 7/1/2021 12/31/2299 ventilator Battery charger; replacement for patient-owned A4613 1 per month 7/1/2021 12/31/2299 ventilator A4614 Peak expiratory flow rate meter hand held 1 per month 7/1/2021 12/31/2299 A4615 Cannula nasal 4 per month 7/1/2021 12/31/2299 A4616 Tubing (oxygen) per foot 31 per month 7/1/2021 12/31/2299 A4617 Mouth piece 4 per month 7/1/2021 12/31/2299 A4618 Breathing circuits 4 per month 7/1/2021 12/31/2299 A4619 Face tent 4 per month 7/1/2021 12/31/2299 A4620 Variable concentration mask 4 per month 7/1/2021 12/31/2299
296
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date A4623 Tracheostomy inner cannula 10 per month 7/1/2021 12/31/2299 Tracheal suction catheter any type other than closed A4624 200 per month 7/1/2021 12/31/2299 system each A4625 Tracheostomy care kit for new tracheostomy 100 per month 7/1/2021 12/31/2299 A4626 Tracheostomy cleaning brush each 8 per month 7/1/2021 12/31/2299 A4628 Oropharyngeal suction catheter each 16 per month 7/1/2021 12/31/2299 A4629 Tracheostomy care kit for established tracheostomy 100 per month 7/1/2021 12/31/2299 Replacement batteries medically necessary A4630 1 per month 7/1/2021 12/31/2299 transcutaneous electrical stimulator o Replacement bulb/lamp for ultraviolet light therapy A4633 4 per month 7/1/2021 12/31/2299 system each Replacement bulb for therapeutic light box tabletop A4634 4 per month 7/1/2021 12/31/2299 model A4635 Underarm pad crutch replacement each 2 per month 7/1/2021 12/31/2299 A4636 Replacement handgrip cane crutch or walker each 2 per month 7/1/2021 12/31/2299 A4637 Replacement tip cane crutch walker each. 4 per month 7/1/2021 12/31/2299 Replacement pad for use with medically necessary A4640 1 per month 7/1/2021 12/31/2299 alternating pressure pad owned A4649 Surgical supply; miscellaneous 1 per month 7/1/2021 12/31/2299 Sphygmomanometer/blood pressure apparatus with A4660 1 per 3 years 7/1/2021 12/31/2299 cuff and stethoscope A4663 Blood pressure cuff only 1 per month 7/1/2021 12/31/2299 A4670 Automatic blood pressure monitor 1 per 3 years 7/1/2021 12/31/2299 A4927 Gloves non-sterile per 100 3 per month 7/1/2021 12/31/2299 A4930 Gloves sterile per pair 200 per month 7/1/2021 12/31/2299
297
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ostomy pouch closed; with barrier attached (1 piece) A5051 60 per month 7/1/2021 12/31/2299 each Ostomy pouch closed; without barrier attached (1 A5052 60 per month 7/1/2021 12/31/2299 piece) each A5053 Ostomy pouch closed; for use on faceplate each 60 per month 7/1/2021 12/31/2299 Ostomy pouch closed; for use on barrier with flange A5054 60 per month 7/1/2021 12/31/2299 (2 piece) each A5055 Stoma cap 31 per month 7/1/2021 12/31/2299 Ostomy pouch drainable with extended wear barrier A5056 20 per month 7/1/2021 12/31/2299 attached with filter (1 piece) Ostomy pouch drainable with extended wear barrier A5057 20 per month 7/1/2021 12/31/2299 attached with built in convexi Ostomy pouch drainable; with barrier attached (1 A5061 60 per month 7/1/2021 12/31/2299 piece) each Ostomy pouch drainable; without barrier attached (1 A5062 60 per month 7/1/2021 12/31/2299 piece) each Ostomy pouch drainable; for use on barrier with A5063 60 per month 7/1/2021 12/31/2299 flange (2 piece system) each Ostomy pouch urinary; with barrier attached (1 piece) A5071 60 per month 7/1/2021 12/31/2299 each Ostomy pouch urinary; without barrier attached (1 A5072 60 per month 7/1/2021 12/31/2299 piece) each Ostomy pouch urinary; for use on barrier with flange A5073 60 per month 7/1/2021 12/31/2299 (2 piece) each A5081 Stoma plug or seal any type 31 per month 7/1/2021 12/31/2299 A5082 Continent device; catheter for continent stoma 10 per month 7/1/2021 12/31/2299
298
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Continent device stoma absorptive cover for continent A5083 20 per month 7/1/2021 12/31/2299 stoma A5093 Ostomy accessory; convex insert 10 per month 7/1/2021 12/31/2299 Bedside drainage bottle with or without tubing rigid or A5102 1 per month 7/1/2021 12/31/2299 expandable each Urinary suspensory with leg bag with or without tube A5105 8 per month 7/1/2021 12/31/2299 each Urinary drainage bag leg or abdomen latex with or A5112 4 per month 7/1/2021 12/31/2299 without tube with straps each A5113 Leg strap; latex replacement only per set 4 per month 7/1/2021 12/31/2299 A5114 Leg strap; foam or fabric replacement only per set 2 per month 7/1/2021 12/31/2299 A5120 Skin barrier wipes or swabs each 100 per month 7/1/2021 12/31/2299 A5121 Skin barrier; solid 6 x 6 or equivalent each 31 per month 7/1/2021 12/31/2299 A5122 Skin barrier; solid 8 x 8 or equivalent each 31 per month 7/1/2021 12/31/2299 A5126 Adhesive or non-adhesive; disk or foam pad 31 per month 7/1/2021 12/31/2299 Appliance cleaner incontinence and ostomy A5131 2 per month 7/1/2021 12/31/2299 appliances per 16 oz. Percutaneous catheter/tube anchoring device A5200 31 per month 7/1/2021 12/31/2299 adhesive skin attachment For diabetics only fitting (including follow-up) custom A5500 4 per month 7/1/2021 12/31/2299 preparation and supply o For diabetics only fitting (including follow-up) custom A5501 4 per month 7/1/2021 12/31/2299 preparation and supply o For diabetics only modification (including fitting) of off- A5503 4 per month 7/1/2021 12/31/2299 the-shelf depth-inlay For diabetics only modification (including fitting) of off- A5504 4 per month 7/1/2021 12/31/2299 the-shelf depth-inlay
299
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date For diabetics only modification (including fitting) of off- A5505 4 per month 7/1/2021 12/31/2299 the-shelf depth-inlay For diabetics only modification (including fitting) of off- A5506 4 per month 7/1/2021 12/31/2299 the-shelf depth-inlay For diabetics only not otherwise specified A5507 4 per month 7/1/2021 12/31/2299 modification (including fitting) of o For diabetics only direct formed compression molded A5510 4 per month 7/1/2021 12/31/2299 to patient's foot without ex For diabetics only multiple density insert direct formed cannot be combined with A5512 4 per 6 months 7/1/2021 12/31/2299 molded to foot after ex A5513 For diabetics only multiple density insert custom cannot be combined with A5513 4 per 6 months 7/1/2021 12/31/2299 molded from model of patient's A5512 For diabetics only multiple density insert made by A5514 4 per 6 months 7/1/2021 12/31/2299 direct carving with cam techn Collagen based wound filler dry form sterile per gram A6010 31 per month 7/1/2021 12/31/2299 of collagen Collagen based wound filler gel/paste per gram of A6011 31 per month 7/1/2021 12/31/2299 collagen A6021 Collagen dressing sterile size 16 sq. in. or less each 31 per month 7/1/2021 12/31/2299 Collagen dressing sterile size more than 16 sq. in. but A6022 31 per month 7/1/2021 12/31/2299 less than or equal to 48 Collagen dressing sterile size more than 48 sq. in. A6023 10 per month 7/1/2021 12/31/2299 each A6024 Collagen dressing wound filler sterile per 6 inches 31 per month 7/1/2021 12/31/2299 A6154 Wound pouch each 31 per month 7/1/2021 12/31/2299 Alginate or other fiber gelling dressing wound cover A6196 31 per month 7/1/2021 12/31/2299 sterile pad size 16 sq. in.
300
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Alginate or other fiber gelling dressing wound cover A6197 31 per month 7/1/2021 12/31/2299 sterile pad size more than Alginate or other fiber gelling dressing wound cover A6198 16 per month 7/1/2021 12/31/2299 sterile pad size more than Alginate or other fiber gelling dressing wound filler A6199 60 per month 7/1/2021 12/31/2299 sterile per 6 inches Composite dressing sterile pad size 16 sq. in. or less A6203 31 per month 7/1/2021 12/31/2299 with any size adhesive bo Composite dressing sterile pad size more than 16 sq. A6204 31 per month 7/1/2021 12/31/2299 in. but less than or equal Composite dressing sterile pad size more than 48 sq. A6205 16 per month 7/1/2021 12/31/2299 in. with any size adhesive A6206 Contact layer sterile 16 sq. in. or less each dressing 31 per month 7/1/2021 12/31/2299 Contact layer sterile more than 16 sq. in. but less A6207 31 per month 7/1/2021 12/31/2299 than or equal to 48 sq. in. Contact layer sterile more than 48 sq. in. each A6208 16 per month 7/1/2021 12/31/2299 dressing Foam dressing wound cover sterile pad size 16 sq. in. A6209 31 per month 7/1/2021 12/31/2299 or less without adhesive b Foam dressing wound cover sterile pad size more A6210 31 per month 7/1/2021 12/31/2299 than 16 sq. in. but less than or Foam dressing wound cover sterile pad size more A6211 31 per month 7/1/2021 12/31/2299 than 48 sq. in. without adhesive Foam dressing wound cover sterile pad size 16 sq. in. A6212 31 per month 7/1/2021 12/31/2299 or less with any size adhe Foam dressing wound cover sterile pad size more A6213 31 per month 7/1/2021 12/31/2299 than 16 sq. in. but less than or
301
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Foam dressing wound cover sterile pad size more A6214 31 per month 7/1/2021 12/31/2299 than 48 sq. in. with any size ad A6215 Foam dressing wound filler sterile per gram 16 per month 7/1/2021 12/31/2299 Gauze non-impregnated non-sterile pad size 16 sq. A6216 200 per month 7/1/2021 12/31/2299 in. or less without adhesive b Gauze non-impregnated non-sterile pad size more A6217 200 per month 7/1/2021 12/31/2299 than 16 sq. in. but less than or Gauze non-impregnated non-sterile pad size more A6218 200 per month 7/1/2021 12/31/2299 than 48 sq. in. without adhesive Gauze non-impregnated sterile pad size 16 sq. in. or A6219 150 per month 7/1/2021 12/31/2299 less with any size adhesive Gauze non-impregnated sterile pad size more than A6220 100 per month 7/1/2021 12/31/2299 16 sq. in. but less than or equ Gauze non-impregnated sterile pad size more than A6221 31 per month 7/1/2021 12/31/2299 48 sq. in. with any size adhesi Gauze impregnated with other than water normal A6222 31 per month 7/1/2021 12/31/2299 saline or hydrogel sterile pad si Gauze impregnated with other than water normal A6223 60 per month 7/1/2021 12/31/2299 saline or hydrogel sterile pad si Gauze impregnated with other than water normal A6224 31 per month 7/1/2021 12/31/2299 saline or hydrogel sterile pad si Gauze impregnated water or normal saline sterile pad A6229 31 per month 7/1/2021 12/31/2299 size more than 16 sq. in. b Gauze impregnated hydrogel for direct wound contact A6231 31 per month 7/1/2021 12/31/2299 sterile pad size 16 sq. in. Gauze impregnated hydrogel for direct wound contact A6232 31 per month 7/1/2021 12/31/2299 sterile pad size greater tha
302
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Gauze impregnated hydrogel for direct wound contact A6233 31 per month 7/1/2021 12/31/2299 sterile pad size more than 4 Hydrocolloid dressing wound cover sterile pad size 16 A6234 31 per month 7/1/2021 12/31/2299 sq. in. or less without ad Hydrocolloid dressing wound cover sterile pad size A6235 31 per month 7/1/2021 12/31/2299 more than 16 sq. in. but less Hydrocolloid dressing wound cover sterile pad size A6236 31 per month 7/1/2021 12/31/2299 more than 48 sq. in. without Hydrocolloid dressing wound cover sterile pad size 16 A6237 31 per month 7/1/2021 12/31/2299 sq. in. or less with any s Hydrocolloid dressing wound cover sterile pad size A6238 31 per month 7/1/2021 12/31/2299 more than 16 sq. in. but less Hydrocolloid dressing wound cover sterile pad size A6239 31 per month 7/1/2021 12/31/2299 more than 48 sq. in. with any Hydrocolloid dressing wound filler paste sterile per A6240 20 per month 7/1/2021 12/31/2299 ounce Hydrocolloid dressing wound filler dry form sterile per A6241 20 per month 7/1/2021 12/31/2299 gram Hydrogel dressing wound cover sterile pad size 16 A6242 31 per month 7/1/2021 12/31/2299 sq. in. or less without adhesi Hydrogel dressing wound cover sterile pad size more A6243 8 per month 7/1/2021 12/31/2299 than 16 sq. in. but less tha Hydrogel dressing wound cover sterile pad size more A6244 8 per month 7/1/2021 12/31/2299 than 48 sq. in. without adhe Hydrogel dressing wound cover sterile pad size 16 A6245 8 per month 7/1/2021 12/31/2299 sq. in. or less with any size Hydrogel dressing wound cover sterile pad size more A6246 8 per month 7/1/2021 12/31/2299 than 16 sq. in. but less tha
303
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Hydrogel dressing wound cover sterile pad size more A6247 8 per month 7/1/2021 12/31/2299 than 48 sq. in. with any siz A6248 Hydrogel dressing wound filler gel per fluid ounce 31 per month 7/1/2021 12/31/2299 Specialty absorptive dressing wound cover sterile pad A6251 31 per month 7/1/2021 12/31/2299 size 16 sq. in. or less wi Specialty absorptive dressing wound cover sterile pad A6252 31 per month 7/1/2021 12/31/2299 size more than 16 sq. in. Specialty absorptive dressing wound cover sterile pad A6253 31 per month 7/1/2021 12/31/2299 size more than 48 sq. in. Specialty absorptive dressing wound cover sterile pad A6254 31 per month 7/1/2021 12/31/2299 size 16 sq. in. or less wi Specialty absorptive dressing wound cover sterile pad A6255 31 per month 7/1/2021 12/31/2299 size more than 16 sq. in. Specialty absorptive dressing wound cover sterile pad A6256 31 per month 7/1/2021 12/31/2299 size more than 48 sq. in. Transparent film sterile 16 sq. in. or less each A6257 31 per month 7/1/2021 12/31/2299 dressing Transparent film sterile more than 16 sq. in. but less A6258 31 per month 7/1/2021 12/31/2299 than or equal to 48 sq. i Transparent film sterile more than 48 sq. in. each A6259 31 per month 7/1/2021 12/31/2299 dressing Wound filler gel/paste per fluid ounce not otherwise A6261 31 per month 7/1/2021 12/31/2299 specified Wound filler dry form per gram not otherwise A6262 31 per month 7/1/2021 12/31/2299 specified Gauze impregnated other than water normal saline or A6266 31 per month 7/1/2021 12/31/2299 zinc paste sterile any width
304
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Gauze non-impregnated sterile pad size 16 sq. in. or A6402 200 per month 7/1/2021 12/31/2299 less without adhesive borde Gauze non-impregnated sterile pad size more than A6403 150 per month 7/1/2021 12/31/2299 16 sq. in. less than or equal t Gauze non-impregnated sterile pad size more than A6404 31 per month 7/1/2021 12/31/2299 48 sq. in. without adhesive bor Packing strips non-impregnated sterile up to 2 inches A6407 31 per month 7/1/2021 12/31/2299 in width per linear yard A6410 Eye pad sterile each 60 per month 7/1/2021 12/31/2299 A6412 Eye patch occlusive each 31 per month 7/1/2021 12/31/2299 Padding bandage non-elastic non-woven/non-knitted A6441 60 per month 7/1/2021 12/31/2299 width greater than or equal to Conforming bandage non-elastic knitted/woven non- A6442 100 per month 7/1/2021 12/31/2299 sterile width less than three i Conforming bandage non-elastic knitted/woven non- A6443 100 per month 7/1/2021 12/31/2299 sterile width greater than or e Conforming bandage non-elastic knitted/woven non- A6444 100 per month 7/1/2021 12/31/2299 sterile width greater than or e Conforming bandage non-elastic knitted/woven sterile A6445 150 per month 7/1/2021 12/31/2299 width less than three inche Conforming bandage non-elastic knitted/woven sterile A6446 150 per month 7/1/2021 12/31/2299 width greater than or equal Conforming bandage non-elastic knitted/woven sterile A6447 150 per month 7/1/2021 12/31/2299 width greater than or equal Light compression bandage elastic knitted/woven A6448 100 per month 7/1/2021 12/31/2299 width less than three inches per Light compression bandage elastic knitted/woven A6449 100 per month 7/1/2021 12/31/2299 width greater than or equal to t
305
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Light compression bandage elastic knitted/woven A6450 100 per month 7/1/2021 12/31/2299 width greater than or equal to f Moderate compression bandage elastic knitted/woven A6451 100 per month 7/1/2021 12/31/2299 load resistance of 1.25 to 1. High compression bandage elastic knitted/woven load A6452 31 per month 7/1/2021 12/31/2299 resistance greater than or e Self-adherent bandage elastic non-knitted/non-woven A6453 31 per month 7/1/2021 12/31/2299 width less than three inches Self-adherent bandage elastic non-knitted/non-woven A6454 31 per month 7/1/2021 12/31/2299 width greater than or equal Self-adherent bandage elastic non-knitted/non-woven A6455 31 per month 7/1/2021 12/31/2299 width greater than or equal Zinc paste impregnated bandage non-elastic A6456 31 per month 7/1/2021 12/31/2299 knitted/woven width greater than or e Tubular dressing with or without elastic any width per A6457 31 per month 7/1/2021 12/31/2299 linear yard Compression burn garment bodysuit (head to foot) A6501 1 per month 7/1/2021 12/31/2299 custom fabricated Compression burn garment chin strap custom A6502 1 per month 7/1/2021 12/31/2299 fabricated Compression burn garment facial hood custom A6503 1 per month 7/1/2021 12/31/2299 fabricated Compression burn garment glove to wrist custom A6504 2 per month 7/1/2021 12/31/2299 fabricated Compression burn garment glove to elbow custom A6505 2 per month 7/1/2021 12/31/2299 fabricated Compression burn garment glove to axilla custom A6506 2 per month 7/1/2021 12/31/2299 fabricated
306
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Compression burn garment foot to knee length A6507 2 per month 7/1/2021 12/31/2299 custom fabricated Compression burn garment foot to thigh length A6508 2 per month 7/1/2021 12/31/2299 custom fabricated Compression burn garment upper trunk to waist A6509 1 per month 7/1/2021 12/31/2299 including arm openings (vest) cust Compression burn garment trunk including arms A6510 1 per month 7/1/2021 12/31/2299 down to leg openings (leotard) cus Compression burn garment lower trunk including leg A6511 1 per month 7/1/2021 12/31/2299 openings (panty) custom fabri A6512 Compression burn garment not otherwise classified 2 per month 7/1/2021 12/31/2299 Compression burn mask face and/or neck plastic or A6513 1 per month 7/1/2021 12/31/2299 equal custom fabricated Gradient compression stocking below knee 18-30 A6530 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking below knee 30-40 A6531 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking below knee 40-50 A6532 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking thigh length 18-30 A6533 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking thigh length 30-40 A6534 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking thigh length 40-50 A6535 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking full length/chap style A6536 4 per 6 months 7/1/2021 12/31/2299 18-30 mmhg each
307
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Gradient compression stocking full length/chap style A6537 4 per 6 months 7/1/2021 12/31/2299 30-40 mmhg each Gradient compression stocking full length/chap style A6538 4 per 6 months 7/1/2021 12/31/2299 40-50 mmhg each Gradient compression stocking waist length 18-30 A6539 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking waist length 30-40 A6540 4 per 6 months 7/1/2021 12/31/2299 mmhg each Gradient compression stocking waist length 40-50 A6541 4 per 6 months 7/1/2021 12/31/2299 mmhg each A6544 Gradient compression stocking garter belt 4 per 6 months 7/1/2021 12/31/2299 Gradient compression wrap non-elastic below knee A6545 4 per 6 months 7/1/2021 12/31/2299 30-50 mm hg each Gradient compression stocking/sleeve not otherwise A6549 14 per month 7/1/2021 12/31/2299 specified Wound care set for negative pressure wound therapy A6550 31 per month 7/1/2021 12/31/2299 electrical pump includes all A7000 Canister disposable used with suction pump each 8 per month 7/1/2021 12/31/2299 Canister non-disposable used with suction pump A7001 1 per month 7/1/2021 12/31/2299 each A7002 Tubing used with suction pump each 2 per month 7/1/2021 12/31/2299 Administration set with small volume nonfiltered A7003 2 per month 7/1/2021 12/31/2299 pneumatic nebulizer disposable Small volume nonfiltered pneumatic nebulizer A7004 2 per month 7/1/2021 12/31/2299 disposable Administration set with small volume nonfiltered A7005 1 per month 7/1/2021 12/31/2299 pneumatic nebulizer non-disposa
308
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Administration set with small volume filtered A7006 1 per month 7/1/2021 12/31/2299 pneumatic nebulizer Large volume nebulizer disposable unfilled used with A7007 4 per month 7/1/2021 12/31/2299 aerosol compressor Large volume nebulizer disposable prefilled used with A7008 4 per month 7/1/2021 12/31/2299 aerosol compressor Reservoir bottle non-disposable used with large A7009 2 per month 7/1/2021 12/31/2299 volume ultrasonic nebulizer Corrugated tubing disposable used with large volume A7010 2 per month 7/1/2021 12/31/2299 nebulizer 100 feet Water collection device used with large volume A7012 2 per month 7/1/2021 12/31/2299 nebulizer Filter disposable used with aerosol compressor or A7013 2 per month 7/1/2021 12/31/2299 ultrasonic generator Filter nondisposable used with aerosol compressor or A7014 1 per month 7/1/2021 12/31/2299 ultrasonic generator A7015 Aerosol mask used with dme nebulizer 1 per month 7/1/2021 12/31/2299 Dome and mouthpiece used with small volume A7016 1 per month 7/1/2021 12/31/2299 ultrasonic nebulizer Nebulizer durable glass or autoclavable plastic bottle A7017 1 per month 7/1/2021 12/31/2299 type not used with oxygen Water distilled used with large volume nebulizer 1000 A7018 31 per month 7/1/2021 12/31/2299 ml Interface for cough stimulating device includes all A7020 1 per month 7/1/2021 12/31/2299 components replacement only High frequency chest wall oscillation system vest A7025 1 per 3 years 7/1/2021 12/31/2299 replacement for use with patie
309
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date High frequency chest wall oscillation system hose A7026 1 per 3 years 7/1/2021 12/31/2299 replacement for use with patie Combination oral/nasal mask used with continuous A7027 1 per 3 months 7/1/2021 12/31/2299 positive airway pressure device Oral cushion for combination oral/nasal mask A7028 2 per month 7/1/2021 12/31/2299 replacement only each Nasal pillows for combination oral/nasal mask A7029 2 per month 7/1/2021 12/31/2299 replacement only pair Full face mask used with positive airway pressure cannot be combined with A7030 1 per 3 months 7/1/2021 12/31/2299 device each A7034 Face mask interface replacement for full face mask cannot be combined with A7031 1 per month 7/1/2021 12/31/2299 each A7032 Cushion for use on nasal mask interface replacement cannot be combined with A7032 2 per month 7/1/2021 12/31/2299 only each A7031 Pillow for use on nasal cannula type interface A7033 2 per month 7/1/2021 12/31/2299 replacement only pair Nasal interface (mask or cannula type) used with cannot be combined with A7034 1 per 3 months 7/1/2021 12/31/2299 positive airway pressure device A7030 A7035 Headgear used with positive airway pressure device 1 per 6 months 7/1/2021 12/31/2299 A7036 Chinstrap used with positive airway pressure device 1 per 6 months 7/1/2021 12/31/2299 cannot be combined with A7037 Tubing used with positive airway pressure device 1 per month 7/1/2021 12/31/2299 A4604 Filter disposable used with positive airway pressure A7038 2 per month 7/1/2021 12/31/2299 device Filter non disposable used with positive airway A7039 1 per 6 months 7/1/2021 12/31/2299 pressure device A7040 One way chest drain valve 2 per month 7/1/2021 12/31/2299
310
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Water seal drainage container and tubing for use with A7041 4 per month 7/1/2021 12/31/2299 implanted chest tube Oral interface used with positive airway pressure A7044 1 per month 7/1/2021 12/31/2299 device each Exhalation port with or without swivel used with A7045 1 per 6 months 7/1/2021 12/31/2299 accessories for positive airway Water chamber for humidifier used with positive A7046 1 per 6 months 7/1/2021 12/31/2299 airway pressure device replaceme Oral interface used with respiratory suction pump A7047 2 per month 7/1/2021 12/31/2299 each Vacuum drainage collection unit and tubing kit A7048 4 per month 7/1/2021 12/31/2299 including all supplies needed for A7501 Tracheostoma valve including diaphragm each 1 per month 7/1/2021 12/31/2299 Replacement diaphragm/faceplate for tracheostoma A7502 1 per month 7/1/2021 12/31/2299 valve each Filter holder or filter cap reusable for use in a A7503 3 per month 7/1/2021 12/31/2299 tracheostoma heat and moisture Filter for use in a tracheostoma heat and moisture A7504 31 per month 7/1/2021 12/31/2299 exchange system each Housing reusable without adhesive for use in a heat A7505 8 per month 7/1/2021 12/31/2299 and moisture exchange system Adhesive disc for use in a heat and moisture A7506 31 per month 7/1/2021 12/31/2299 exchange system and/or with tracheo Filter holder and integrated filter without adhesive for A7507 31 per month 7/1/2021 12/31/2299 use in a tracheostoma h Housing and integrated adhesive for use in a A7508 8 per month 7/1/2021 12/31/2299 tracheostoma heat and moisture exch
311
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Filter holder and integrated filter housing and A7509 31 per month 7/1/2021 12/31/2299 adhesive for use as a tracheosto Tracheostomy/laryngectomy tube non-cuffed A7520 4 per month 7/1/2021 12/31/2299 polyvinylchloride (pvc) silicone or eq Tracheostomy/laryngectomy tube cuffed A7521 4 per month 7/1/2021 12/31/2299 polyvinylchloride (pvc) silicone or equal Tracheostomy/laryngectomy tube stainless steel or A7522 1 per month 7/1/2021 12/31/2299 equal (sterilizable and reusab A7523 Tracheostomy shower protector each 8 per month 7/1/2021 12/31/2299 A7524 Tracheostoma stent/stud/button each 4 per month 7/1/2021 12/31/2299 A7525 Tracheostomy mask each 8 per month 7/1/2021 12/31/2299 A7526 Tracheostomy tube collar/holder each 31 per month 7/1/2021 12/31/2299 A7527 Tracheostomy/laryngectomy tube plug/stop each 8 per month 7/1/2021 12/31/2299 Helmet protective soft prefabricated includes all A8000 1 per month 7/1/2021 12/31/2299 components and accessories Helmet protective hard prefabricated includes all A8001 1 per month 7/1/2021 12/31/2299 components and accessories Helmet protective soft custom fabricated includes all A8002 1 per month 7/1/2021 12/31/2299 components and accessories Helmet protective hard custom fabricated includes all A8003 1 per month 7/1/2021 12/31/2299 components and accessories Cold or hot fluid bottle ice cap or collar heat and/or A9273 1 per year 7/1/2021 12/31/2299 cold wrap any type External ambulatory insulin delivery system A9274 20 per month 7/1/2021 12/31/2299 disposable each includes all supplie A9275 Home glucose disposable monitor includes test strips 1 per month 7/1/2021 12/31/2299
312
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Sensor; invasive (e.g. subcutaneous) disposable for A9276 15 per month 7/1/2021 12/31/2299 use with interstitial contin Transmitter; external for use with interstitial A9277 1 per month 7/1/2021 12/31/2299 continuous glucose monitoring sy Receiver (monitor); external for use with interstitial A9278 1 per month 7/1/2021 12/31/2299 continuous glucose monito A9281 Reaching/grabbing device any type any length each 1 per month 7/1/2021 12/31/2299 A9282 Wig any type each 1 per month 7/1/2021 12/31/2299 Foot pressure off loading/supportive device any type 2 pairs per A9283 7/1/2021 12/31/2299 each year A9284 Spirometer non-electronic includes all accessories 1 per month 7/1/2021 12/31/2299 Hygienic item or device disposable or non-disposable A9286 1 per month 7/1/2021 12/31/2299 any type each Miscellaneous dme supply accessory and/or service A9900 2 per month 7/1/2021 12/31/2299 component of another hcpcs cod Miscellaneous dme supply accessory and/or service A9900 2 per month 7/1/2021 12/31/2299 component of another hcpcs cod Miscellaneous dme supply or accessory not A9999 100 per month 7/1/2021 12/31/2299 otherwise specified Miscellaneous dme supply or accessory not A9999 100 per month 7/1/2021 12/31/2299 otherwise specified Cane includes canes of all materials adjustable or E0100 1 per 2 years 7/1/2021 12/31/2299 fixed with tip Cane quad or three prong includes canes of all E0105 1 per 2 years 7/1/2021 12/31/2299 materials adjustable or fixed wit Crutches forearm includes crutches of various E0110 1 per 3 years 7/1/2021 12/31/2299 materials adjustable or fixed pair
313
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Crutch forearm includes crutches of various materials E0111 1 per 3 years 7/1/2021 12/31/2299 adjustable or fixed each w Crutches underarm wood adjustable or fixed pair with E0112 1 per 3 years 7/1/2021 12/31/2299 pads tips and handgrips Crutch underarm wood adjustable or fixed each with E0113 1 per 3 years 7/1/2021 12/31/2299 pad tip and handgrip Crutches underarm other than wood adjustable or E0114 1 per 3 years 7/1/2021 12/31/2299 fixed pair with pads tips and ha Crutch underarm other than wood adjustable or fixed E0116 1 per 3 years 7/1/2021 12/31/2299 with pad tip handgrip with o Crutch substitute lower leg platform with or without E0118 1 per 3 years 7/1/2021 12/31/2299 wheels each E0130 Walker rigid (pickup) adjustable or fixed height 1 per 3 years 7/1/2021 12/31/2299 E0135 Walker folding (pickup) adjustable or fixed height 1 per 3 years 7/1/2021 12/31/2299 Walker with trunk support adjustable or fixed height E0140 1 per 3 years 7/1/2021 12/31/2299 any type E0141 Walker rigid wheeled adjustable or fixed height 1 per 3 years 7/1/2021 12/31/2299 E0143 Walker folding wheeled adjustable or fixed height 1 per 3 years 7/1/2021 12/31/2299 Walker enclosed four sided framed rigid or folding E0144 1 per 3 years 7/1/2021 12/31/2299 wheeled with posterior seat Walker heavy duty multiple braking system variable E0147 1 per 3 years 7/1/2021 12/31/2299 wheel resistance Walker heavy duty without wheels rigid or folding any E0148 1 per 3 years 7/1/2021 12/31/2299 type each E0149 Walker heavy duty wheeled rigid or folding any type 1 per 3 years 7/1/2021 12/31/2299 E0153 Platform attachment forearm crutch each 1 per 2 years 7/1/2021 12/31/2299 E0154 Platform attachment walker each 1 per 2 years 7/1/2021 12/31/2299
314
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date E0155 Wheel attachment rigid pick-up walker per pair 1 per 2 years 7/1/2021 12/31/2299 E0156 Seat attachment walker 1 per 3 years 7/1/2021 12/31/2299 E0157 Crutch attachment walker each 1 per 2 years 7/1/2021 12/31/2299 E0158 Leg extensions for walker per set of four (4) 1 per 2 years 7/1/2021 12/31/2299 Brake attachment for wheeled walker replacement E0159 1 per 2 years 7/1/2021 12/31/2299 each Sitz type bath or equipment portable used with or E0160 1 per 2 years 7/1/2021 12/31/2299 without commode Sitz type bath or equipment portable used with or E0161 1 per 2 years 7/1/2021 12/31/2299 without commode with faucet at E0162 Sitz bath chair 1 per 2 years 7/1/2021 12/31/2299 E0163 Commode chair mobile or stationary with fixed arms 1 per 5 years 7/1/2021 12/31/2299 Commode chair mobile or stationary with detachable E0165 1 per 5 years 7/1/2021 12/31/2299 arms Pail or pan for use with commode chair replacement E0167 1 per 2 years 7/1/2021 12/31/2299 only Commode chair extra wide and/or heavy duty E0168 1 per 2 years 7/1/2021 12/31/2299 stationary or mobile with or without Commode chair with integrated seat lift mechanism E0170 1 per 2 years 7/1/2021 12/31/2299 electric any type Commode chair with integrated seat lift mechanism E0171 1 per 2 years 7/1/2021 12/31/2299 non-electric any type E0175 Foot rest for use with commode chair each 1 per 5 years 7/1/2021 12/31/2299 Powered pressure reducing mattress overlay/pad E0181 1 per 5 years 7/1/2021 12/31/2299 alternating with pump includes he Pump for alternating pressure pad for replacement E0182 1 per 5 years 7/1/2021 12/31/2299 only
315
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date E0184 Dry pressure mattress 1 per year 7/1/2021 12/31/2299 Gel or gel-like pressure pad for mattress standard E0185 1 per year 7/1/2021 12/31/2299 mattress length and width E0186 Air pressure mattress 1 per year 7/1/2021 12/31/2299 E0187 Water pressure mattress 1 per year 7/1/2021 12/31/2299 E0188 Synthetic sheepskin pad 1 per year 7/1/2021 12/31/2299 E0191 Heel or elbow protector each 2 per year 7/1/2021 12/31/2299 E0193 Powered air flotation bed (low air loss therapy) 1 per 3 years 7/1/2021 12/31/2299 E0196 Gel pressure mattress 1 per year 7/1/2021 12/31/2299 Air pressure pad for mattress standard mattress E0197 1 per year 7/1/2021 12/31/2299 length and width Water pressure pad for mattress standard mattress E0198 1 per year 7/1/2021 12/31/2299 length and width Dry pressure pad for mattress standard mattress E0199 1 per year 7/1/2021 12/31/2299 length and width E0210 Electric heat pad standard 1 per 3 years 7/1/2021 12/31/2299 E0215 Electric heat pad moist 1 per 3 years 7/1/2021 12/31/2299 E0240 Bath/shower chair with or without wheels any size 1 per 5 years 7/1/2021 12/31/2299 E0241 Bath tub wall rail each 2 per 3 years 7/1/2021 12/31/2299 E0243 Toilet rail each 1 per 3 years 7/1/2021 12/31/2299 E0244 Raised toilet seat 1 per 2 years 7/1/2021 12/31/2299 E0245 Tub stool or bench 1 per 2 years 7/1/2021 12/31/2299 Transfer bench for tub or toilet with or without E0247 1 per 2 years 7/1/2021 12/31/2299 commode opening
316
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Transfer bench heavy duty for tub or toilet with or E0248 1 per 2 years 7/1/2021 12/31/2299 without commode opening Pad for water circulating heat unit for replacement E0249 1 per 5 years 7/1/2021 12/31/2299 only Hospital bed fixed height with any type side rails with E0250 1 per 5 years 7/1/2021 12/31/2299 mattress Hospital bed fixed height with any type side rails E0251 1 per 5 years 7/1/2021 12/31/2299 without mattress Hospital bed variable height hi-lo with any type side E0255 1 per 5 years 7/1/2021 12/31/2299 rails with mattress Hospital bed variable height hi-lo with any type side E0256 1 per 5 years 7/1/2021 12/31/2299 rails without mattress Hospital bed semi-electric (head and foot adjustment) E0260 1 per 5 years 7/1/2021 12/31/2299 with any type side rails w Hospital bed semi-electric (head and foot adjustment) E0261 1 per 5 years 7/1/2021 12/31/2299 with any type side rails w Hospital bed total electric (head foot and height E0265 1 per 5 years 7/1/2021 12/31/2299 adjustments) with any type sid Hospital bed total electric (head foot and height E0266 1 per 5 years 7/1/2021 12/31/2299 adjustments) with any type sid E0271 Mattress innerspring 1 per 2 years 7/1/2021 12/31/2299 E0272 Mattress foam rubber 1 per 2 years 7/1/2021 12/31/2299 E0275 Bed pan standard metal or plastic 1 per 3 years 7/1/2021 12/31/2299 E0276 Bed pan fracture metal or plastic 1 per 3 years 7/1/2021 12/31/2299 E0277 Powered pressure-reducing air mattress 1 per 5 years 7/1/2021 12/31/2299 Hospital bed fixed height without side rails with E0290 1 per 5 years 7/1/2021 12/31/2299 mattress
317
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Hospital bed fixed height without side rails without E0291 1 per 5 years 7/1/2021 12/31/2299 mattress Hospital bed variable height hi-lo without side rails E0292 1 per 5 years 7/1/2021 12/31/2299 with mattress Hospital bed variable height hi-lo without side rails E0293 1 per 5 years 7/1/2021 12/31/2299 without mattress Hospital bed semi-electric (head and foot adjustment) E0294 1 per 5 years 7/1/2021 12/31/2299 without side rails with ma Hospital bed semi-electric (head and foot adjustment) E0295 1 per 5 years 7/1/2021 12/31/2299 without side rails without Hospital bed total electric (head foot and height E0296 1 per 5 years 7/1/2021 12/31/2299 adjustments) without side rail Hospital bed total electric (head foot and height E0297 1 per 5 years 7/1/2021 12/31/2299 adjustments) without side rail Hospital bed heavy duty extra wide with weight E0301 1 per 5 years 7/1/2021 12/31/2299 capacity greater than 350 pounds Hospital bed extra heavy duty extra wide with weight E0302 1 per 5 years 7/1/2021 12/31/2299 capacity greater than 600 p Hospital bed heavy duty extra wide with weight E0303 1 per 5 years 7/1/2021 12/31/2299 capacity greater than 350 pounds Hospital bed extra heavy duty extra wide with weight E0304 1 per 5 years 7/1/2021 12/31/2299 capacity greater than 600 p E0305 Bed side rails half length 1 per 2 years 7/1/2021 12/31/2299 E0310 Bed side rails full length 1 per 2 years 7/1/2021 12/31/2299 Safety enclosure frame/canopy for use with hospital E0316 1 per 5 years 7/1/2021 12/31/2299 bed any type E0325 Urinal; male jug-type any material 2 per year 7/1/2021 12/31/2299
318
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date E0326 Urinal; female jug-type any material 1 per 5 years 7/1/2021 12/31/2299 Nonpowered advanced pressure reducing overlay for E0371 1 per 5 years 7/1/2021 12/31/2299 mattress standard mattress len Powered air overlay for mattress standard mattress E0372 1 per 5 years 7/1/2021 12/31/2299 length and width Stationary compressed gaseous oxygen system continous E0424 7/1/2021 12/31/2299 rental; includes container contents monthly rental Portable gaseous oxygen system rental; includes continous E0431 7/1/2021 12/31/2299 portable container regulator flo monthly rental Portable liquid oxygen system rental; home liquefier continous E0433 7/1/2021 12/31/2299 used to fill portable liqui monthly rental Portable liquid oxygen system rental; includes continous E0434 7/1/2021 12/31/2299 portable container supply reservo monthly rental Stationary liquid oxygen system rental; includes continous E0439 7/1/2021 12/31/2299 container contents regulator fl monthly rental Stationary oxygen contents gaseous 1 month's continous E0441 7/1/2021 12/31/2299 supply = 1 unit monthly rental Stationary oxygen contents liquid 1 month's supply = continous E0442 7/1/2021 12/31/2299 1 unit monthly rental Portable oxygen contents gaseous 1 month's supply continous E0443 7/1/2021 12/31/2299 = 1 unit monthly rental Portable oxygen contents liquid 1 month's supply = 1 continous E0444 7/1/2021 12/31/2299 unit monthly rental Respiratory assist device bi-level pressure capability E0470 1 per 5 years 7/1/2021 12/31/2299 without backup rate featu Respiratory assist device bi-level pressure capability E0471 1 per 5 years 7/1/2021 12/31/2299 with back-up rate feature
319
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Respiratory assist device bi-level pressure capability E0472 1 per 5 years 7/1/2021 12/31/2299 with backup rate feature E0480 Percussor electric or pneumatic home model 1 per 5 years 7/1/2021 12/31/2299 Oral device/appliance used to reduce upper airway E0485 1 per 5 years 7/1/2021 12/31/2299 collapsibility adjustable or n Oral device/appliance used to reduce upper airway E0486 1 per 5 years 7/1/2021 12/31/2299 collapsibility adjustable or n E0487 Spirometer electronic includes all accessories 1 per 5 years 7/1/2021 12/31/2299 Humidifier durable for extensive supplemental E0550 1 per 5 years 7/1/2021 12/31/2299 humidification during ippb treatme Humidifier durable for supplemental humidification E0560 1 per 5 years 7/1/2021 12/31/2299 during ippb treatment or oxyg Humidifier non-heated used with positive airway E0561 1 per 5 years 7/1/2021 12/31/2299 pressure device Humidifier heated used with positive airway pressure E0562 1 per 5 years 7/1/2021 12/31/2299 device Compressor air power source for equipment which is E0565 1 per 5 years 7/1/2021 12/31/2299 not self-contained or cylinde E0570 Nebulizer with compressor 1 per year 7/1/2021 12/31/2299 Aerosol compressor adjustable pressure light duty for E0572 1 per 5 years 7/1/2021 12/31/2299 intermittent use Ultrasonic/electronic aerosol generator with small E0574 1 per 5 years 7/1/2021 12/31/2299 volume nebulizer E0575 Nebulizer ultrasonic large volume 1 per 5 years 7/1/2021 12/31/2299 Nebulizer durable glass or autoclavable plastic bottle E0580 1 per month 7/1/2021 12/31/2299 type for use with regulat E0585 Nebulizer with compressor and heater 1 per 5 years 7/1/2021 12/31/2299
320
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Respiratory suction pump home model portable or E0600 1 per 5 years 7/1/2021 12/31/2299 stationary electric E0601 Continuous positive airway pressure (cpap) device 1 per 5 years 7/1/2021 12/31/2299 1 per 2 E0603 Breast pump electric (ac and/or dc) any type 7/1/2021 12/31/2299 calendar years E0605 Vaporizer room type 1 per 2 years 7/1/2021 12/31/2299 E0606 Postural drainage board 1 per 5 years 7/1/2021 12/31/2299 E0607 Home blood glucose monitor 1 per 2 years 7/1/2021 12/31/2299 E0625 Patient lift bathroom or toilet not otherwise classified 1 per 5 years 7/1/2021 12/31/2299 E0627 Seat lift mechanism electric any type 1 per 5 years 7/1/2021 12/31/2299 E0629 Seat lift mechanism non-electric any type 1 per 5 years 7/1/2021 12/31/2299 Patient lift hydraulic or mechanical includes any seat E0630 1 per 5 years 7/1/2021 12/31/2299 sling strap(s) or pad(s) E0635 Patient lift electric with seat or sling 1 per 5 years 7/1/2021 12/31/2299 Multipositional patient support system with integrated E0636 1 per 5 years 7/1/2021 12/31/2299 lift patient accessible c Combination sit to stand frame/table system any size E0637 1 per 5 years 7/1/2021 12/31/2299 including pediatric with se Standing frame/table system one position (e.g. E0638 1 per 5 years 7/1/2021 12/31/2299 upright supine or prone stander) Standing frame/table system multi-position (e.g. E0641 1 per 5 years 7/1/2021 12/31/2299 three-way stander) any size inc Standing frame/table system mobile (dynamic E0642 1 per 5 years 7/1/2021 12/31/2299 stander) any size including pediatri E0650 Pneumatic compressor non-segmental home model 1 per 5 years 7/1/2021 12/31/2299
321
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Pneumatic compressor segmental home model E0651 1 per 5 years 7/1/2021 12/31/2299 without calibrated gradient pressure Pneumatic compressor segmental home model with E0652 1 per 5 years 7/1/2021 12/31/2299 calibrated gradient pressure Non-segmental pneumatic appliance for use with E0655 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor half arm Segmental pneumatic appliance for use with E0656 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor trunk Segmental pneumatic appliance for use with E0657 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor chest Non-segmental pneumatic appliance for use with E0660 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor full leg Non-segmental pneumatic appliance for use with E0665 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor full arm Non-segmental pneumatic appliance for use with E0666 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor half leg Segmental pneumatic appliance for use with E0667 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor full leg Segmental pneumatic appliance for use with E0668 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor full arm Segmental pneumatic appliance for use with E0669 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor half leg Segmental pneumatic appliance for use with E0670 1 per 5 years 7/1/2021 12/31/2299 pneumatic compressor integrated 2 ful Segmental gradient pressure pneumatic appliance full E0671 1 per 5 years 7/1/2021 12/31/2299 leg Segmental gradient pressure pneumatic appliance full E0672 1 per 5 years 7/1/2021 12/31/2299 arm
322
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Segmental gradient pressure pneumatic appliance E0673 1 per 5 years 7/1/2021 12/31/2299 half leg Pneumatic compression device high pressure rapid E0675 1 per 5 years 7/1/2021 12/31/2299 inflation/deflation cycle for a Intermittent limb compression device (includes all E0676 1 per 5 years 7/1/2021 12/31/2299 accessories) not otherwise sp Ultraviolet light therapy system includes bulbs/lamps E0691 1 per 5 years 7/1/2021 12/31/2299 timer and eye protection; Ultraviolet light therapy system panel includes E0692 1 per 5 years 7/1/2021 12/31/2299 bulbs/lamps timer and eye protec Ultraviolet light therapy system panel includes E0693 1 per 5 years 7/1/2021 12/31/2299 bulbs/lamps timer and eye protec Ultraviolet multidirectional light therapy system in 6 E0694 1 per 5 years 7/1/2021 12/31/2299 foot cabinet includes bul E0700 Safety equipment device or accessory any type 1 per 2 years 7/1/2021 12/31/2299 E0705 Transfer device any type each 1 per year 7/1/2021 12/31/2299 Transcutaneous electrical nerve stimulation (tens) E0720 1 per 5 years 7/1/2021 12/31/2299 device two lead localized sti Transcutaneous electrical nerve stimulation (tens) E0730 1 per 2 years 7/1/2021 12/31/2299 device four or more leads for Form fitting conductive garment for delivery of tens or E0731 1 per 5 years 7/1/2021 12/31/2299 nmes (with conductive fi Non-implanted pelvic floor electrical stimulator E0740 1 per 5 years 7/1/2021 12/31/2299 complete system E0744 Neuromuscular stimulator for scoliosis 1 per 5 years 7/1/2021 12/31/2299 E0745 Neuromuscular stimulator electronic shock unit 1 per 5 years 7/1/2021 12/31/2299
323
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Transcutaneous electrical joint stimulation device E0762 1 per 5 years 7/1/2021 12/31/2299 system includes all accessori Electrical stimulation or electromagnetic wound E0769 1 per 5 years 7/1/2021 12/31/2299 treatment device not otherwise c Functional electrical stimulator transcutaneous E0770 1 per 5 years 7/1/2021 12/31/2299 stimulation of nerve and/or musc Ambulatory infusion pump mechanical reusable for E0779 1 per 5 years 7/1/2021 12/31/2299 infusion 8 hours or greater Ambulatory infusion pump mechanical reusable for E0780 1 per 5 years 7/1/2021 12/31/2299 infusion less than 8 hours Ambulatory infusion pump single or multiple channels E0781 1 per 5 years 7/1/2021 12/31/2299 electric or battery operate Infusion pump implantable non-programmable E0782 1 per 5 years 7/1/2021 12/31/2299 (includes all components e.g. pump ca Infusion pump system implantable programmable E0783 1 per 5 years 7/1/2021 12/31/2299 (includes all components e.g. pump Parenteral infusion pump stationary single or multi- E0791 1 per 5 years 7/1/2021 12/31/2299 channel Traction frame attached to headboard cervical E0840 1 per 5 years 7/1/2021 12/31/2299 traction Traction equipment cervical free-standing E0849 1 per 5 years 7/1/2021 12/31/2299 stand/frame pneumatic applying tractio E0850 Traction stand free standing cervical traction 1 per 5 years 7/1/2021 12/31/2299 Cervical traction equipment not requiring additional E0855 1 per 5 years 7/1/2021 12/31/2299 stand or frame E0856 Cervical traction device with inflatable air bladder(s) 1 per 5 years 7/1/2021 12/31/2299 E0860 Traction equipment overdoor cervical 1 per 5 years 7/1/2021 12/31/2299
324
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Traction frame attached to footboard extremity E0870 1 per 5 years 7/1/2021 12/31/2299 traction (e.g. buck's) E0880 Traction stand free standing extremity traction 1 per 5 years 7/1/2021 12/31/2299 E0890 Traction frame attached to footboard pelvic traction 1 per 5 years 7/1/2021 12/31/2299 Traction stand free standing pelvic traction (e.g. E0900 1 per 5 years 7/1/2021 12/31/2299 buck's) Trapeze bars a/k/a patient helper attached to bed E0910 1 per 5 years 7/1/2021 12/31/2299 with grab bar Trapeze bar heavy duty for patient weight capacity E0911 1 per 5 years 7/1/2021 12/31/2299 greater than 250 pounds attac Trapeze bar heavy duty for patient weight capacity E0912 1 per 5 years 7/1/2021 12/31/2299 greater than 250 pounds free E0920 Fracture frame attached to bed includes weights 1 per 5 years 7/1/2021 12/31/2299 E0930 Fracture frame free standing includes weights 1 per 5 years 7/1/2021 12/31/2299 E0940 Trapeze bar free standing complete with grab bar 1 per 5 years 7/1/2021 12/31/2299 E0941 Gravity assisted traction device any type 1 per 5 years 7/1/2021 12/31/2299 E0942 Cervical head harness/halter 1 per 5 years 7/1/2021 12/31/2299 E0944 Pelvic belt/harness/boot 1 per year 7/1/2021 12/31/2299 Fracture frame dual with cross bars attached to bed E0946 1 per 5 years 7/1/2021 12/31/2299 (e.g. balken 4 poster) Speech generating device digitized speech using pre- E2500 1 per 5 years 7/1/2021 12/31/2299 recorded messages less than Speech generating device digitized speech using pre- E2502 1 per 5 years 7/1/2021 12/31/2299 recorded messages greater th Speech generating device digitized speech using pre- E2504 1 per 5 years 7/1/2021 12/31/2299 recorded messages greater th
325
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Speech generating device digitized speech using pre- E2506 1 per 5 years 7/1/2021 12/31/2299 recorded messages greater th Speech generating device synthesized speech E2508 1 per 5 years 7/1/2021 12/31/2299 requiring message formulation by spe Speech generating device synthesized speech E2510 1 per 5 years 7/1/2021 12/31/2299 permitting multiple methods of messa Accessory for speech generating device mounting E2512 1 per 5 years 7/1/2021 12/31/2299 system K0001 Standard wheelchair 1 per 3 years 7/1/2021 12/31/2299 K0002 Standard hemi (low seat) wheelchair 1 per 3 years 7/1/2021 12/31/2299 K0003 Lightweight wheelchair 1 per 5 years 7/1/2021 12/31/2299 K0004 High strength lightweight wheelchair 1 per 5 years 7/1/2021 12/31/2299 K0006 Heavy duty wheelchair 1 per 5 years 7/1/2021 12/31/2299 K0007 Extra heavy duty wheelchair 1 per 5 years 7/1/2021 12/31/2299 Supply allowance for therapeutic continuous glucose K0553 1 per month 7/1/2021 12/31/2299 monitor (cgm) includes all s Replacement battery for external infusion pump K0601 6 per year 7/1/2021 12/31/2299 owned by patient silver oxide 1.5 Replacement battery for external infusion pump K0602 2 per year 7/1/2021 12/31/2299 owned by patient silver oxide 3 v Replacement battery for external infusion pump K0603 6 per year 7/1/2021 12/31/2299 owned by patient alkaline 1.5 vol Replacement battery for external infusion pump K0604 2 per year 7/1/2021 12/31/2299 owned by patient lithium 3.6 volt Replacement battery for external infusion pump K0605 2 per year 7/1/2021 12/31/2299 owned by patient lithium 4.5 volt
326
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Automatic external defibrillator with integrated K0606 1 per month 7/1/2021 12/31/2299 electrocardiogram analysis garm Power operated vehicle group 1 standard patient K0800 1 per 5 years 7/1/2021 12/31/2299 weight capacity up to and includ Power operated vehicle group 1 heavy duty patient K0801 1 per 5 years 7/1/2021 12/31/2299 weight capacity 301 to 450 pou Power operated vehicle group 1 very heavy duty K0802 1 per 5 years 7/1/2021 12/31/2299 patient weight capacity 451 to 60 Power operated vehicle group 2 standard patient K0806 1 per 5 years 7/1/2021 12/31/2299 weight capacity up to and includ Power operated vehicle group 2 heavy duty patient K0807 1 per 5 years 7/1/2021 12/31/2299 weight capacity 301 to 450 pou Power operated vehicle group 2 very heavy duty K0808 1 per 5 years 7/1/2021 12/31/2299 patient weight capacity 451 to 60 K0812 Power operated vehicle not otherwise classified 1 per 5 years 7/1/2021 12/31/2299 Cranial cervical orthosis congenital torticollis type with L0112 2 per year 7/1/2021 12/31/2299 or without soft inter Cranial cervical orthosis torticollis type with or without L0113 2 per year 7/1/2021 12/31/2299 joint with or without Cervical flexible non-adjustable prefabricated off-the- L0120 2 per year 7/1/2021 12/31/2299 shelf (foam collar) L0130 Cervical flexible thermoplastic collar molded to patient 2 per year 7/1/2021 12/31/2299 L0140 Cervical semi-rigid adjustable (plastic collar) 1 per year 7/1/2021 12/31/2299 Cervical semi-rigid adjustable molded chin cup L0150 1 per year 7/1/2021 12/31/2299 (plastic collar with mandibular/o Cervical semi-rigid wire frame occipital/mandibular L0160 1 per year 7/1/2021 12/31/2299 support prefabricated off-th
327
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date L0170 Cervical collar molded to patient model 1 per year 7/1/2021 12/31/2299 Cervical collar semi-rigid thermoplastic foam two- L0172 1 per year 7/1/2021 12/31/2299 piece prefabricated off-the-sh Cervical collar semi-rigid thermoplastic foam two L0174 1 per year 7/1/2021 12/31/2299 piece with thoracic extension Cervical multiple post collar occipital/mandibular L0180 1 per year 7/1/2021 12/31/2299 supports adjustable Cervical multiple post collar occipital/mandibular L0190 1 per year 7/1/2021 12/31/2299 supports adjustable cervical Cervical multiple post collar occipital/mandibular L0200 1 per year 7/1/2021 12/31/2299 supports adjustable cervical L0220 Thoracic rib belt custom fabricated 1 per year 7/1/2021 12/31/2299 Tlso flexible provides trunk support upper thoracic L0450 1 per year 7/1/2021 12/31/2299 region produces intracavitar Tlso flexible provides trunk support upper thoracic L0452 1 per year 7/1/2021 12/31/2299 region produces intracavitar Tlso flexible provides trunk support extends from L0454 1 per year 7/1/2021 12/31/2299 sacrococcygeal junction to abo Tlso flexible provides trunk support thoracic region L0456 1 per year 7/1/2021 12/31/2299 rigid posterior panel and s Tlso triplanar control modular segmented spinal L0460 1 per year 7/1/2021 12/31/2299 system two rigid plastic shells Tlso sagittal control rigid posterior frame and flexible L0466 1 per year 7/1/2021 12/31/2299 soft anterior apron wit Tlso sagittal-coronal control rigid posterior frame and L0468 1 per year 7/1/2021 12/31/2299 flexible soft anterior a Tlso triplanar control rigid posterior frame and flexible L0470 1 per year 7/1/2021 12/31/2299 soft anterior apron wi
328
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Tlso triplanar control hyperextension rigid anterior L0472 1 per year 7/1/2021 12/31/2299 and lateral frame extends f Tlso triplanar control one piece rigid plastic shell L0480 2 per year 7/1/2021 12/31/2299 without interface liner wit Tlso triplanar control one piece rigid plastic shell with L0482 2 per year 7/1/2021 12/31/2299 interface liner multip Tlso triplanar control two piece rigid plastic shell L0484 1 per year 7/1/2021 12/31/2299 without interface liner wit Tlso triplanar control two piece rigid plastic shell with L0486 2 per year 7/1/2021 12/31/2299 interface liner multip Tlso triplanar control one piece rigid plastic shell with L0488 1 per year 7/1/2021 12/31/2299 interface liner multip Tlso sagittal-coronal control one piece rigid plastic L0490 1 per year 7/1/2021 12/31/2299 shell with overlapping rei Tlso sagittal-coronal control modular segmented L0491 1 per year 7/1/2021 12/31/2299 spinal system two rigid plastic Tlso sagittal-coronal control modular segmented L0492 1 per year 7/1/2021 12/31/2299 spinal system three rigid plasti Sacroiliac orthosis flexible provides pelvic-sacral L0621 1 per year 7/1/2021 12/31/2299 support reduces motion about Sacroiliac orthosis flexible provides pelvic-sacral L0621 1 per year 7/1/2021 12/31/2299 support reduces motion about Sacroiliac orthosis flexible provides pelvic-sacral L0622 1 per year 7/1/2021 12/31/2299 support reduces motion about Lumbar orthosis flexible provides lumbar support L0625 1 per year 7/1/2021 12/31/2299 posterior extends from l-1 to b Lumbar orthosis flexible provides lumbar support L0625 1 per year 7/1/2021 12/31/2299 posterior extends from l-1 to b
329
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Lumbar orthosis sagittal control with rigid posterior L0626 1 per year 7/1/2021 12/31/2299 panel(s) posterior extends Lumbar orthosis sagittal control with rigid anterior and L0627 1 per year 7/1/2021 12/31/2299 posterior panels poster Lumbar-sacral orthosis flexible provides lumbo-sacral L0628 1 per 2 years 7/1/2021 12/31/2299 support posterior extends Lumbar-sacral orthosis flexible provides lumbo-sacral L0628 1 per year 7/1/2021 12/31/2299 support posterior extends Lumbar-sacral orthosis sagittal control with rigid L0630 1 per 2 years 7/1/2021 12/31/2299 posterior panel(s) posterior Lumbar-sacral orthosis sagittal control with rigid L0631 1 per 2 years 7/1/2021 12/31/2299 anterior and posterior panels Lumbar-sacral orthosis sagittal-coronal control with L0633 1 per 2 years 7/1/2021 12/31/2299 rigid posterior frame/panel Lumbar-sacral orthosis sagittal-coronal control lumbar L0635 1 per 2 years 7/1/2021 12/31/2299 flexion rigid posterior f Lumbar sacral orthosis sagittal-coronal control lumbar L0636 1 per 2 years 7/1/2021 12/31/2299 flexion rigid posterior f Lumbar-sacral orthosis sagittal-coronal control with L0637 1 per 2 years 7/1/2021 12/31/2299 rigid anterior and posterio Lumbar-sacral orthosis sagittal-coronal control with L0638 1 per 2 years 7/1/2021 12/31/2299 rigid anterior and posterio Lumbar-sacral orthosis sagittal-coronal control rigid L0639 1 per 2 years 7/1/2021 12/31/2299 shell(s)/panel(s) posterio Lumbar-sacral orthosis sagittal-coronal control rigid L0640 1 per 2 years 7/1/2021 12/31/2299 shell(s)/panel(s) posterio Lumbar orthosis sagittal control with rigid posterior L0641 1 per 2 years 7/1/2021 12/31/2299 panel(s) posterior extends
330
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Lumbar orthosis sagittal control with rigid anterior and L0642 1 per 2 years 7/1/2021 12/31/2299 posterior panels poster Lumbar-sacral orthosis sagittal control with rigid L0643 1 per 2 years 7/1/2021 12/31/2299 posterior panel(s) posterior Lumbar-sacral orthosis sagittal-coronal control with L0649 1 per 2 years 7/1/2021 12/31/2299 rigid posterior frame/panel Cervical-thoracic-lumbar-sacral-orthoses (ctlso) L0700 1 per year 7/1/2021 12/31/2299 anterior-posterior-lateral cont Ctlso anterior-posterior-lateral-control molded to L0710 1 per year 7/1/2021 12/31/2299 patient model with interface Halo procedure cervical halo incorporated into jacket L0810 1 per 2 years 7/1/2021 12/31/2299 vest Halo procedure cervical halo incorporated into plaster L0820 1 per 2 years 7/1/2021 12/31/2299 body jacket Halo procedure cervical halo incorporated into L0830 1 per 2 years 7/1/2021 12/31/2299 milwaukee type orthosis Addition to halo procedure magnetic resonance L0859 1 per year 7/1/2021 12/31/2299 image compatible systems rings and Addition to halo procedure replacement liner/interface L0861 1 per year 7/1/2021 12/31/2299 material L0970 Tlso corset front 1 per year 7/1/2021 12/31/2299 L0972 Lso corset front 1 per year 7/1/2021 12/31/2299 L0974 Tlso full corset 1 per year 7/1/2021 12/31/2299 L0976 Lso full corset 1 per year 7/1/2021 12/31/2299 L0978 Axillary crutch extension 2 per year 7/1/2021 12/31/2299 L0980 Peroneal straps prefabricated off-the-shelf pair 1 per year 7/1/2021 12/31/2299
331
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Stocking supporter grips prefabricated off-the-shelf L0982 2 per year 7/1/2021 12/31/2299 set of four (4) L0984 Protective body sock prefabricated off-the-shelf each 6 per year 7/1/2021 12/31/2299 L0999 Addition to spinal orthosis not otherwise specified 1 per year 7/1/2021 12/31/2299 Cervical-thoracic-lumbar-sacral orthosis (ctlso) L1000 2 per year 7/1/2021 12/31/2299 (milwaukee) inclusive of furnis Cervical thoracic lumbar sacral orthosis immobilizer L1001 2 per year 7/1/2021 12/31/2299 infant size prefabricated i Tension based scoliosis orthosis and accessory pads L1005 1 per year 7/1/2021 12/31/2299 includes fitting and adjustm Addition to cervical-thoracic-lumbar-sacral orthosis L1010 2 per year 7/1/2021 12/31/2299 (ctlso) or scoliosis orthos L1020 Addition to ctlso or scoliosis orthosis kyphosis pad 2 per year 7/1/2021 12/31/2299 Addition to ctlso or scoliosis orthosis kyphosis pad L1025 2 per year 7/1/2021 12/31/2299 floating Addition to ctlso or scoliosis orthosis lumbar bolster L1030 2 per year 7/1/2021 12/31/2299 pad Addition to ctlso or scoliosis orthosis lumbar or L1040 2 per year 7/1/2021 12/31/2299 lumbar rib pad L1050 Addition to ctlso or scoliosis orthosis sternal pad 2 per year 7/1/2021 12/31/2299 L1060 Addition to ctlso or scoliosis orthosis thoracic pad 2 per year 7/1/2021 12/31/2299 L1070 Addition to ctlso or scoliosis orthosis trapezius sling 2 per year 7/1/2021 12/31/2299 L1080 Addition to ctlso or scoliosis orthosis outrigger 2 per year 7/1/2021 12/31/2299 Addition to ctlso or scoliosis orthosis outrigger L1085 2 per year 7/1/2021 12/31/2299 bilateral with vertical extens L1090 Addition to ctlso or scoliosis orthosis lumbar sling 2 per year 7/1/2021 12/31/2299
332
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Addition to ctlso or scoliosis orthosis ring flange L1100 2 per year 7/1/2021 12/31/2299 plastic or leather Addition to ctlso or scoliosis orthosis ring flange L1110 2 per year 7/1/2021 12/31/2299 plastic or leather molded to Addition to ctlso scoliosis orthosis cover for upright L1120 2 per year 7/1/2021 12/31/2299 each Thoracic-lumbar-sacral-orthosis (tlso) inclusive of L1200 2 per year 7/1/2021 12/31/2299 furnishing initial orthosis L1210 Addition to tlso (low profile) lateral thoracic extension 2 per year 7/1/2021 12/31/2299 Addition to tlso (low profile) anterior thoracic L1220 2 per year 7/1/2021 12/31/2299 extension Addition to tlso (low profile) milwaukee type L1230 2 per year 7/1/2021 12/31/2299 superstructure L1240 Addition to tlso (low profile) lumbar derotation pad 2 per year 7/1/2021 12/31/2299 L1250 Addition to tlso (low profile) anterior asis pad 3 per year 7/1/2021 12/31/2299 Addition to tlso (low profile) anterior thoracic L1260 3 per year 7/1/2021 12/31/2299 derotation pad L1270 Addition to tlso (low profile) abdominal pad 3 per year 7/1/2021 12/31/2299 L1280 Addition to tlso (low profile) rib gusset (elastic) each 3 per year 7/1/2021 12/31/2299 L1290 Addition to tlso (low profile) lateral trochanteric pad 3 per year 7/1/2021 12/31/2299 Other scoliosis procedure body jacket molded to L1300 1 per 3 years 7/1/2021 12/31/2299 patient model L1310 Other scoliosis procedure post-operative body jacket 1 per 3 years 7/1/2021 12/31/2299 Hip orthosis abduction control of hip joints flexible L1600 2 per year 7/1/2021 12/31/2299 frejka type with cover pre Hip orthosis abduction control of hip joints flexible L1610 2 per year 7/1/2021 12/31/2299 (frejka cover only) prefab
333
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Hip orthosis abduction control of hip joints flexible L1620 2 per year 7/1/2021 12/31/2299 (pavlik harness) prefabric Hip orthosis abduction control of hip joints semi- L1630 2 per year 7/1/2021 12/31/2299 flexible (von rosen type) cust Hip orthosis abduction control of hip joints static L1640 2 per year 7/1/2021 12/31/2299 pelvic band or spreader bar Hip orthosis abduction control of hip joints static L1650 2 per year 7/1/2021 12/31/2299 adjustable (ilfled type) pre Hip orthosis bilateral thigh cuffs with adjustable L1652 2 per year 7/1/2021 12/31/2299 abductor spreader bar adult s Hip orthosis abduction control of hip joints static L1660 2 per year 7/1/2021 12/31/2299 plastic prefabricated includ Hip orthosis abduction control of hip joints dynamic L1680 2 per year 7/1/2021 12/31/2299 pelvic control adjustable h Hip orthosis abduction control of hip joint L1685 2 per year 7/1/2021 12/31/2299 postoperative hip abduction type cus Hip orthosis abduction control of hip joint L1686 2 per year 7/1/2021 12/31/2299 postoperative hip abduction type pre Combination bilateral lumbo-sacral hip femur orthosis L1690 2 per year 7/1/2021 12/31/2299 providing adduction and in Legg perthes orthosis (toronto type) custom L1700 2 per year 7/1/2021 12/31/2299 fabricated Legg perthes orthosis (newington type) custom L1710 2 per year 7/1/2021 12/31/2299 fabricated Legg perthes orthosis trilateral (tachdijan type) L1720 2 per year 7/1/2021 12/31/2299 custom fabricated Legg perthes orthosis (scottish rite type) custom L1730 2 per year 7/1/2021 12/31/2299 fabricated
334
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Legg perthes orthosis (patten bottom type) custom L1755 2 per year 7/1/2021 12/31/2299 fabricated Knee orthosis elastic with joints prefabricated item L1810 2 per year 7/1/2021 12/31/2299 that has been trimmed bent Knee orthosis elastic with joints prefabricated off-the- L1812 2 per year 7/1/2021 12/31/2299 shelf Knee orthosis elastic with condylar pads and joints L1820 2 per year 7/1/2021 12/31/2299 with or without patellar con Knee orthosis immobilizer canvas longitudinal L1830 2 per year 7/1/2021 12/31/2299 prefabricated off-the-shelf Knee orthosis locking knee joint(s) positional orthosis L1831 2 per year 7/1/2021 12/31/2299 prefabricated includes f Knee orthosis adjustable knee joints (unicentric or L1832 2 per year 7/1/2021 12/31/2299 polycentric) positional orth Knee orthosis without knee joint rigid custom L1834 2 per year 7/1/2021 12/31/2299 fabricated Knee orthosis rigid without joint(s) includes soft L1836 2 per year 7/1/2021 12/31/2299 interface material prefabrica Knee orthosis derotation medial-lateral anterior L1840 2 per year 7/1/2021 12/31/2299 cruciate ligament custom fabric Knee orthosis single upright thigh and calf with L1843 2 per year 7/1/2021 12/31/2299 adjustable flexion and extensio Knee orthosis single upright thigh and calf with L1844 2 per year 7/1/2021 12/31/2299 adjustable flexion and extensio Knee orthosis double upright thigh and calf with L1845 2 per year 7/1/2021 12/31/2299 adjustable flexion and extensio Knee orthosis double upright thigh and calf with L1846 2 per year 7/1/2021 12/31/2299 adjustable flexion and extensio
335
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Knee orthosis double upright with adjustable joint with L1847 2 per year 7/1/2021 12/31/2299 inflatable air support c L1850 Knee orthosis swedish type prefabricated off-the-shelf 2 per year 7/1/2021 12/31/2299 Knee orthosis modification of supracondylar L1860 2 per year 7/1/2021 12/31/2299 prosthetic socket custom fabricated Ankle foot orthosis spring wire dorsiflexion assist calf L1900 2 per year 7/1/2021 12/31/2299 band custom fabricated Ankle orthosis ankle gauntlet or similar with or without L1902 4 per year 7/1/2021 12/31/2299 joints prefabricated of Ankle orthosis ankle gauntlet or similar with or without L1904 4 per year 7/1/2021 12/31/2299 joints custom fabricate Ankle foot orthosis multiligamentous ankle support L1906 4 per year 7/1/2021 12/31/2299 prefabricated off-the-shelf Ankle orthosis supramalleolar with straps with or L1907 4 per year 7/1/2021 12/31/2299 without interface/pads custom Ankle foot orthosis posterior single bar clasp L1910 2 per year 7/1/2021 12/31/2299 attachment to shoe counter prefab Ankle foot orthosis single upright with static or L1920 2 per year 7/1/2021 12/31/2299 adjustable stop (phelps or per Ankle foot orthosis plastic or other material L1930 4 per year 7/1/2021 12/31/2299 prefabricated includes fitting and Afo rigid anterior tibial section total carbon fiber or L1932 2 per year 7/1/2021 12/31/2299 equal material prefabric Ankle foot orthosis plastic or other material custom L1940 2 per year 7/1/2021 12/31/2299 fabricated Ankle foot orthosis plastic rigid anterior tibial section L1945 2 per year 7/1/2021 12/31/2299 (floor reaction) custo
336
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Ankle foot orthosis spiral (institute of rehabilitative L1950 2 per year 7/1/2021 12/31/2299 medicine type) plastic c Ankle foot orthosis spiral (institute of rehabilitative L1951 2 per year 7/1/2021 12/31/2299 medicine type) plastic o Ankle foot orthosis posterior solid ankle plastic L1960 2 per year 7/1/2021 12/31/2299 custom fabricated Ankle foot orthosis plastic with ankle joint custom L1970 2 per year 7/1/2021 12/31/2299 fabricated Ankle foot orthosis plastic or other material with ankle L1971 2 per year 7/1/2021 12/31/2299 joint prefabricated inc Ankle foot orthosis single upright free plantar L1980 2 per year 7/1/2021 12/31/2299 dorsiflexion solid stirrup calf Ankle foot orthosis double upright free plantar L1990 2 per year 7/1/2021 12/31/2299 dorsiflexion solid stirrup calf Knee ankle foot orthosis single upright free knee free L2000 2 per year 7/1/2021 12/31/2299 ankle solid stirrup thigh Knee ankle foot orthosis any material single or double L2005 2 per year 7/1/2021 12/31/2299 upright stance control au Knee ankle foot orthosis single upright free ankle L2010 2 per year 7/1/2021 12/31/2299 solid stirrup thigh and calf Knee ankle foot orthosis double upright free ankle L2020 2 per year 7/1/2021 12/31/2299 solid stirrup thigh and calf Knee ankle foot orthosis double upright free ankle L2030 2 per year 7/1/2021 12/31/2299 solid stirrup thigh and calf Knee ankle foot orthosis full plastic single upright with L2034 2 per year 7/1/2021 12/31/2299 or without free motion Knee ankle foot orthosis full plastic static (pediatric L2035 2 per year 7/1/2021 12/31/2299 size) without free motio
337
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Knee ankle foot orthosis full plastic double upright L2036 2 per year 7/1/2021 12/31/2299 with or without free motion Knee ankle foot orthosis full plastic single upright with L2037 2 per year 7/1/2021 12/31/2299 or without free motion Knee ankle foot orthosis full plastic with or without L2038 2 per year 7/1/2021 12/31/2299 free motion knee multi-axi Hip knee ankle foot orthosis torsion control bilateral L2040 2 per year 7/1/2021 12/31/2299 rotation straps pelvic ba Hip knee ankle foot orthosis torsion control bilateral L2050 2 per year 7/1/2021 12/31/2299 torsion cables hip joint Hip knee ankle foot orthosis torsion control bilateral L2060 2 per year 7/1/2021 12/31/2299 torsion cables ball beari Hip knee ankle foot orthosis torsion control unilateral L2070 2 per year 7/1/2021 12/31/2299 rotation straps pelvic b Hip knee ankle foot orthosis torsion control unilateral L2080 2 per year 7/1/2021 12/31/2299 torsion cable hip joint Hip knee ankle foot orthosis torsion control unilateral L2090 2 per year 7/1/2021 12/31/2299 torsion cable ball beari Ankle foot orthosis fracture orthosis tibial fracture cast L2106 2 per year 7/1/2021 12/31/2299 orthosis thermoplasti Ankle foot orthosis fracture orthosis tibial fracture cast L2108 2 per year 7/1/2021 12/31/2299 orthosis custom fabri Ankle foot orthosis fracture orthosis tibial fracture L2112 2 per year 7/1/2021 12/31/2299 orthosis soft prefabricate Ankle foot orthosis fracture orthosis tibial fracture L2114 2 per year 7/1/2021 12/31/2299 orthosis semi-rigid prefab Ankle foot orthosis fracture orthosis tibial fracture L2116 2 per year 7/1/2021 12/31/2299 orthosis rigid prefabricat
338
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Knee ankle foot orthosis fracture orthosis femoral L2126 2 per year 7/1/2021 12/31/2299 fracture cast orthosis thermo Knee ankle foot orthosis fracture orthosis femoral L2128 2 per year 7/1/2021 12/31/2299 fracture cast orthosis custom Kafo fracture orthosis femoral fracture cast orthosis L2132 2 per year 7/1/2021 12/31/2299 soft prefabricated include Kafo fracture orthosis femoral fracture cast orthosis L2134 2 per year 7/1/2021 12/31/2299 semi-rigid prefabricated i Kafo fracture orthosis femoral fracture cast orthosis L2136 2 per year 7/1/2021 12/31/2299 rigid prefabricated includ Addition to lower extremity fracture orthosis plastic L2180 2 per year 7/1/2021 12/31/2299 shoe insert with ankle joi Addition to lower extremity fracture orthosis drop lock L2182 2 per year 7/1/2021 12/31/2299 knee joint Addition to lower extremity fracture orthosis limited L2184 2 per year 7/1/2021 12/31/2299 motion knee joint Addition to lower extremity fracture orthosis L2186 2 per year 7/1/2021 12/31/2299 adjustable motion knee joint lerma Addition to lower extremity fracture orthosis L2188 2 per year 7/1/2021 12/31/2299 quadrilateral brim L2190 Addition to lower extremity fracture orthosis waist belt 2 per year 7/1/2021 12/31/2299 Addition to lower extremity fracture orthosis hip joint L2192 2 per year 7/1/2021 12/31/2299 pelvic band thigh flange Addition to lower extremity dorsiflexion assist (plantar L2210 4 per year 7/1/2021 12/31/2299 flexion resist) each jo Addition to lower extremity split flat caliper stirrups L2230 2 per year 7/1/2021 12/31/2299 and plate attachment
339
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Addition to lower extremity orthosis rocker bottom for L2232 2 per year 7/1/2021 12/31/2299 total contact ankle foot Addition to lower extremity round caliper and plate L2240 2 per year 7/1/2021 12/31/2299 attachment Addition to lower extremity foot plate molded to L2250 2 per year 7/1/2021 12/31/2299 patient model stirrup attachmen Addition to lower extremity reinforced solid stirrup L2260 2 per year 7/1/2021 12/31/2299 (scott-craig type) L2265 Addition to lower extremity long tongue stirrup 2 per year 7/1/2021 12/31/2299 L2280 Addition to lower extremity molded inner boot 2 per year 7/1/2021 12/31/2299 Addition to lower extremity abduction bar (bilateral hip L2300 2 per year 7/1/2021 12/31/2299 involvement) jointed ad L2310 Addition to lower extremity abduction bar-straight 2 per year 7/1/2021 12/31/2299 Addition to lower extremity non-molded lacer for L2320 2 per year 7/1/2021 12/31/2299 custom fabricated orthosis only Addition to lower extremity lacer molded to patient L2330 2 per year 7/1/2021 12/31/2299 model for custom fabricated L2335 Addition to lower extremity anterior swing band 2 per year 7/1/2021 12/31/2299 Addition to lower extremity pre-tibial shell molded to L2340 2 per year 7/1/2021 12/31/2299 patient model Addition to lower extremity prosthetic type (bk) socket L2350 2 per year 7/1/2021 12/31/2299 molded to patient model L2360 Addition to lower extremity extended steel shank 2 per year 7/1/2021 12/31/2299 L2370 Addition to lower extremity patten bottom 2 per year 7/1/2021 12/31/2299 Addition to lower extremity torsion control ankle joint L2375 2 per year 7/1/2021 12/31/2299 and half solid stirrup
340
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Addition to lower extremity torsion control straight L2380 2 per year 7/1/2021 12/31/2299 knee joint each joint Addition to lower extremity orthosis suspension L2397 2 per year 7/1/2021 12/31/2299 sleeve Addition to lower extremity thigh/weight bearing L2500 2 per year 7/1/2021 12/31/2299 gluteal/ ischial weight bearing Addition to lower extremity thigh/weight bearing L2510 2 per year 7/1/2021 12/31/2299 quadri- lateral brim molded to Addition to lower extremity thigh/weight bearing L2520 2 per year 7/1/2021 12/31/2299 quadri- lateral brim custom fit Addition to lower extremity thigh/weight bearing L2525 2 per year 7/1/2021 12/31/2299 ischial containment/narrow m-l Addition to lower extremity thigh/weight bearing L2526 2 per year 7/1/2021 12/31/2299 ischial containment/narrow m-l Addition to lower extremity thigh-weight bearing lacer L2530 2 per year 7/1/2021 12/31/2299 non-molded Addition to lower extremity thigh/weight bearing lacer L2540 2 per year 7/1/2021 12/31/2299 molded to patient model Addition to lower extremity thigh/weight bearing high L2550 2 per year 7/1/2021 12/31/2299 roll cuff Addition to lower extremity pelvic control hip joint L2570 2 per year 7/1/2021 12/31/2299 clevis type two position jo L2580 Addition to lower extremity pelvic control pelvic sling 2 per year 7/1/2021 12/31/2299 Addition to lower extremity pelvic control hip joint L2600 2 per year 7/1/2021 12/31/2299 clevis type or thrust beari Addition to lower extremity pelvic control hip joint L2610 2 per year 7/1/2021 12/31/2299 clevis or thrust bearing lo
341
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Addition to lower extremity pelvic control hip joint L2620 2 per year 7/1/2021 12/31/2299 heavy duty each Addition to lower extremity pelvic control hip joint L2622 2 per year 7/1/2021 12/31/2299 adjustable flexion each Addition to lower extremity pelvic control hip joint L2624 2 per year 7/1/2021 12/31/2299 adjustable flexion extensio Addition to lower extremity pelvic control plastic L2627 2 per year 7/1/2021 12/31/2299 molded to patient model recip Addition to lower extremity pelvic control metal frame L2628 2 per year 7/1/2021 12/31/2299 reciprocating hip joint a Addition to lower extremity pelvic control band and L2630 2 per year 7/1/2021 12/31/2299 belt unilateral Addition to lower extremity pelvic control band and L2640 2 per year 7/1/2021 12/31/2299 belt bilateral Addition to lower extremity pelvic and thoracic control L2650 2 per year 7/1/2021 12/31/2299 gluteal pad each Addition to lower extremity thoracic control thoracic L2660 2 per year 7/1/2021 12/31/2299 band Addition to lower extremity thoracic control paraspinal L2670 2 per year 7/1/2021 12/31/2299 uprights Addition to lower extremity thoracic control lateral L2680 2 per year 7/1/2021 12/31/2299 support uprights Foot insert removable molded to patient model 'ucb' L3000 4 per year 7/1/2021 12/31/2299 type berkeley shell each Foot insert removable molded to patient model L3001 4 per year 7/1/2021 12/31/2299 spenco each Foot insert removable molded to patient model L3002 4 per year 7/1/2021 12/31/2299 plastazote or equal each
342
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Foot insert removable molded to patient model L3003 4 per year 7/1/2021 12/31/2299 silicone gel each Foot insert removable molded to patient model L3010 4 per year 7/1/2021 12/31/2299 longitudinal arch support each Foot insert removable molded to patient model L3020 4 per year 7/1/2021 12/31/2299 longitudinal/ metatarsal support e L3030 Foot insert removable formed to patient foot each 4 per year 7/1/2021 12/31/2299 Foot insert/plate removable addition to lower L3031 4 per year 7/1/2021 12/31/2299 extremity orthosis high strength l Foot arch support removable premolded longitudinal L3040 4 per year 7/1/2021 12/31/2299 each Foot arch support removable premolded metatarsal L3050 4 per year 7/1/2021 12/31/2299 each Foot arch support removable premolded longitudinal/ L3060 4 per year 7/1/2021 12/31/2299 metatarsal each Foot arch support non-removable attached to shoe L3070 4 per year 7/1/2021 12/31/2299 longitudinal each Foot arch support non-removable attached to shoe L3080 4 per year 7/1/2021 12/31/2299 metatarsal each Foot arch support non-removable attached to shoe L3090 4 per year 7/1/2021 12/31/2299 longitudinal/metatarsal each Hallus-valgus night dynamic splint prefabricated off- L3100 2 per year 7/1/2021 12/31/2299 the-shelf L3140 Foot abduction rotation bar including shoes 2 per year 7/1/2021 12/31/2299 L3150 Foot abduction rotation bar without shoes 2 per year 7/1/2021 12/31/2299 L3160 Foot adjustable shoe-styled positioning device 2 per year 7/1/2021 12/31/2299
343
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Foot plastic silicone or equal heel stabilizer L3170 2 per year 7/1/2021 12/31/2299 prefabricated off-the-shelf each 2 pairs per L3215 Orthopedic footwear ladies shoe oxford each 7/1/2021 12/31/2299 year Orthopedic footwear ladies shoe hightop depth inlay 2 pairs per L3217 7/1/2021 12/31/2299 each year 2 pairs per L3219 Orthopedic footwear mens shoe oxford each 7/1/2021 12/31/2299 year 2 pairs per L3221 Orthopedic footwear mens shoe depth inlay each 7/1/2021 12/31/2299 year Orthopedic footwear mens shoe hightop depth inlay 2 pairs per L3222 7/1/2021 12/31/2299 each year Orthopedic footwear woman's shoe oxford used as 2 pairs per L3224 7/1/2021 12/31/2299 an integral part of a brace (ort year Orthopedic footwear man's shoe oxford used as an 2 pairs per L3225 7/1/2021 12/31/2299 integral part of a brace (ortho year 2 pairs per L3230 Orthopedic footwear custom shoe depth inlay each 7/1/2021 12/31/2299 year Orthopedic footwear custom molded shoe removable 2 pairs per L3250 7/1/2021 12/31/2299 inner mold prosthetic shoe each year Foot shoe molded to patient model silicone shoe 2 pairs per L3251 7/1/2021 12/31/2299 each year Foot shoe molded to patient model plastazote (or 2 pairs per L3252 7/1/2021 12/31/2299 similar) custom fabricated each year Foot molded shoe plastazote (or similar) custom fitted 2 pairs per L3253 7/1/2021 12/31/2299 each year 2 pairs per L3265 Plastazote sandal each 7/1/2021 12/31/2299 year
344
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Wrist hand finger orthosis rigid without joints may L3808 1 per 3 years 7/1/2021 12/31/2299 include soft interface mater Walking boot pneumatic and/or vacuum with or L4360 1 per 2 years 7/1/2021 12/31/2299 without joints Walking boot pneumatic and/or vacuum with or L4361 1 per 2 years 7/1/2021 12/31/2299 without joints L4370 pneumatic full leg splint prefabricated off the shelf 1 per 2 years 7/1/2021 12/31/2299 Walking boot non-pneumatic with or without joints L4386 1 per 2 years 7/1/2021 12/31/2299 with or without interface mate Walking boot non-pneumatic with or without joints L4387 1 per 2 years 7/1/2021 12/31/2299 with or without interface Adult sized disposable incontinence product T4521 216 per month 7/1/2021 12/31/2299 brief/diaper small each Adult sized disposable incontinence product T4522 216 per month 7/1/2021 12/31/2299 brief/diaper medium each Adult sized disposable incontinence product T4523 216 per month 7/1/2021 12/31/2299 brief/diaper large each Adult sized disposable incontinence product T4524 216 per month 7/1/2021 12/31/2299 brief/diaper extra large each Adult sized disposable incontinence product T4525 216 per month 7/1/2021 12/31/2299 protective underwear/pull-on small s Adult sized disposable incontinence product T4526 216 per month 7/1/2021 12/31/2299 protective underwear/pull-on medium Adult sized disposable incontinence product T4527 216 per month 7/1/2021 12/31/2299 protective underwear/pull-on large s Adult sized disposable incontinence product T4528 216 per month 7/1/2021 12/31/2299 protective underwear/pull-on extra l
345
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Pediatric sized disposable incontinence product T4529 250 per month 7/1/2021 12/31/2299 brief/diaper small/medium size e Pediatric sized disposable incontinence product T4530 250 per month 7/1/2021 12/31/2299 brief/diaper large size each Pediatric sized disposable incontinence product T4531 250 per month 7/1/2021 12/31/2299 protective underwear/pull-on sma Pediatric sized disposable incontinence product T4532 250 per month 7/1/2021 12/31/2299 protective underwear/pull-on lar Youth sized disposable incontinence product T4533 250 per month 7/1/2021 12/31/2299 brief/diaper each Youth sized disposable incontinence product T4534 250 per month 7/1/2021 12/31/2299 protective underwear/pull-on each Disposable liner/shield/guard/pad/undergarment for T4535 250 per month 7/1/2021 12/31/2299 incontinence each Incontinence product protective underwear/pull-on T4536 8 per month 7/1/2021 12/31/2299 reusable any size each Incontinence product protective underpad reusable T4537 16 per month 7/1/2021 12/31/2299 bed size each Incontinence product diaper/brief reusable any size T4539 31 per month 7/1/2021 12/31/2299 each Incontinence product protective underpad reusable T4540 16 per month 7/1/2021 12/31/2299 chair size each T4541 Incontinence product disposable underpad large each 250 per month 7/1/2021 12/31/2299 Incontinence product disposable underpad small size T4542 250 per month 7/1/2021 12/31/2299 each Adult sized disposable incontinence product T4543 216 per month 7/1/2021 12/31/2299 protective brief/diaper above extra
346
Table 19 Medical Equipment Devices and Supplies (MEDS) Procedure Codes Quantity Limitation Determinations.
Durable Medical Equipment, Orthotics, Prosthetics, and Supplies have limits on the frequency that items can be dispensed to an eligible member. If a HUSKY member exceeds the limit on an item, prior authorization approval must be requested with accompanying medical documentation as to why the limit needs to be exceeded. Correct Coding Initiative (NCCI/MUE) edits will deny items billed in excess of what CMS allows, however the (NCCI/MUE) edits does not include all possible combinations of correct coding edits or types of unbundling that exist. Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination or items that are not appropriately reported together (unbundled). Please note: Equipment that is in working order should not be replaced, although it may have exceeded its life expectancy. Please refer to the MEDS fee schedule for fee schedule rates, pricing information and prior authorization information. The MEDS fee schedule is published at this link: https://www.ctdssmap.com, then select "Provider", then select "Provider Fee Schedule Download". Procedure Procedure Description Service Limit Special Instructions Effective End date Code Date Adult sized disposable incontinence product T4544 216 per month 7/1/2021 12/31/2299 protective underwear/pull-on above e
Table Listing, Previous Table 19, End of Document
Table 20: List of ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage:
Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M2578 Osteophyte, vertebrae M4003 Postural kyphosis, cervicothoracic region M4004 Postural kyphosis, thoracic region M4005 Postural kyphosis, thoracolumbar region M4012 Other secondary kyphosis, cervical region M4013 Other secondary kyphosis, cervicothoracic region M4014 Other secondary kyphosis, thoracic region M4015 Other secondary kyphosis, thoracolumbar region M40292 Other kyphosis, cervical region M40293 Other kyphosis, cervicothoracic region M40294 Other kyphosis, thoracic region M40295 Other kyphosis, thoracolumbar region M4035 Flatback syndrome, thoracolumbar region M4036 Flatback syndrome, lumbar region M4037 Flatback syndrome, lumbosacral region
347 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M4045 Postural lordosis, thoracolumbar region M4046 Postural lordosis, lumbar region M4047 Postural lordosis, lumbosacral region M4102 Infantile idiopathic scoliosis, cervical region M4103 Infantile idiopathic scoliosis, cervicothoracic region M4104 Infantile idiopathic scoliosis, thoracic region M4105 Infantile idiopathic scoliosis, thoracolumbar region M4106 Infantile idiopathic scoliosis, lumbar region M4107 Infantile idiopathic scoliosis, lumbosacral region M4108 Infantile idiopathic scoliosis, sacr/sacrocygl region M41112 Juvenile idiopathic scoliosis, cervical region M41113 Juvenile idiopathic scoliosis, cervicothoracic region M41114 Juvenile idiopathic scoliosis, thoracic region M41115 Juvenile idiopathic scoliosis, thoracolumbar region M41116 Juvenile idiopathic scoliosis, lumbar region M41117 Juvenile idiopathic scoliosis, lumbosacral region M41122 Adolescent idiopathic scoliosis, cervical region M41123 Adolescent idiopathic scoliosis, cervicothoracic region M41124 Adolescent idiopathic scoliosis, thoracic region M41125 Adolescent idiopathic scoliosis, thoracolumbar region M41126 Adolescent idiopathic scoliosis, lumbar region M41127 Adolescent idiopathic scoliosis, lumbosacral region M4122 Other idiopathic scoliosis, cervical region M4123 Other idiopathic scoliosis, cervicothoracic region M4124 Other idiopathic scoliosis, thoracic region M4125 Other idiopathic scoliosis, thoracolumbar region M4126 Other idiopathic scoliosis, lumbar region M4127 Other idiopathic scoliosis, lumbosacral region M4134 Thoracogenic scoliosis, thoracic region M4135 Thoracogenic scoliosis, thoracolumbar region M4141 Neuromuscular scoliosis, occipito-atlanto-axial region M4142 Neuromuscular scoliosis, cervical region M4143 Neuromuscular scoliosis, cervicothoracic region M4144 Neuromuscular scoliosis, thoracic region M4145 Neuromuscular scoliosis, thoracolumbar region M4146 Neuromuscular scoliosis, lumbar region M4147 Neuromuscular scoliosis, lumbosacral region
348 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M4152 Other secondary scoliosis, cervical region M4153 Other secondary scoliosis, cervicothoracic region M4154 Other secondary scoliosis, thoracic region M4155 Other secondary scoliosis, thoracolumbar region M4156 Other secondary scoliosis, lumbar region M4157 Other secondary scoliosis, lumbosacral region M4182 Other forms of scoliosis, cervical region M4183 Other forms of scoliosis, cervicothoracic region M4184 Other forms of scoliosis, thoracic region M4185 Other forms of scoliosis, thoracolumbar region M4186 Other forms of scoliosis, lumbar region M4187 Other forms of scoliosis, lumbosacral region M436 Torticollis M4641 Discitis, unspecified, occipito-atlanto-axial region M4642 Discitis, unspecified, cervical region M4643 Discitis, unspecified, cervicothoracic region M4644 Discitis, unspecified, thoracic region M4645 Discitis, unspecified, thoracolumbar region M4646 Discitis, unspecified, lumbar region M4647 Discitis, unspecified, lumbosacral region M4648 Discitis, unspecified, sacral and sacrococcygeal region M4649 Discitis, unspecified, multiple sites in spine M47011 Anterior spinal artery comprsn synd, occipt-atlan-ax region M47012 Anterior spinal artery comprsn syndromes, cervical region M47013 Anterior spinal artery comprsn syndromes, cervicothor region M47014 Anterior spinal artery comprsn syndromes, thoracic region M47015 Anterior spinal artery comprsn syndromes, thoracolum region M47016 Anterior spinal artery compression syndromes, lumbar region M47021 Verteb art compression syndromes, occipt-atlan-ax region M47022 Vertebral artery compression syndromes, cervical region M47029 Vertebral artery compression syndromes, site unspecified M4711 Oth spondylosis w myelopathy, occipito-atlanto-axial region M4712 Other spondylosis with myelopathy, cervical region M4713 Other spondylosis with myelopathy, cervicothoracic region M4714 Other spondylosis with myelopathy, thoracic region M4715 Other spondylosis with myelopathy, thoracolumbar region M4716 Other spondylosis with myelopathy, lumbar region
349 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M4721 Oth spondylosis w radiculopathy, occipt-atlan-ax region M4722 Other spondylosis with radiculopathy, cervical region M4723 Other spondylosis with radiculopathy, cervicothoracic region M4724 Other spondylosis with radiculopathy, thoracic region M4725 Other spondylosis with radiculopathy, thoracolumbar region M4726 Other spondylosis with radiculopathy, lumbar region M4727 Other spondylosis with radiculopathy, lumbosacral region M4728 Oth spondylosis w radiculopathy, sacr/sacrocygl region M47811 Spondyls w/o myelpath or radiculopathy, occipt-atlan-ax rgn M47812 Spondylosis w/o myelopathy or radiculopathy, cervical region M47813 Spondyls w/o myelopathy or radiculopathy, cervicothor region M47814 Spondylosis w/o myelopathy or radiculopathy, thoracic region M47815 Spondyls w/o myelopathy or radiculopathy, thoracolum region M47816 Spondylosis w/o myelopathy or radiculopathy, lumbar region M47817 Spondyls w/o myelopathy or radiculopathy, lumbosacr region M47818 Spondyls w/o myelpath or radiculopathy, sacr/sacrocygl rgn M47891 Other spondylosis, occipito-atlanto-axial region M47892 Other spondylosis, cervical region M47893 Other spondylosis, cervicothoracic region M47894 Other spondylosis, thoracic region M47895 Other spondylosis, thoracolumbar region M47896 Other spondylosis, lumbar region M47897 Other spondylosis, lumbosacral region M47898 Other spondylosis, sacral and sacrococcygeal region M4811 Ankylosing hyperostosis, occipito-atlanto-axial region M4812 Ankylosing hyperostosis [Forestier], cervical region M4813 Ankylosing hyperostosis [Forestier], cervicothoracic region M4814 Ankylosing hyperostosis [Forestier], thoracic region M4815 Ankylosing hyperostosis [Forestier], thoracolumbar region M4816 Ankylosing hyperostosis [Forestier], lumbar region M4817 Ankylosing hyperostosis [Forestier], lumbosacral region M4818 Ankylosing hyperostosis, sacral and sacrococcygeal region M4819 Ankylosing hyperostosis [Forestier], multiple sites in spine M4821 Kissing spine, occipito-atlanto-axial region M4822 Kissing spine, cervical region M4823 Kissing spine, cervicothoracic region M4824 Kissing spine, thoracic region
350 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M4825 Kissing spine, thoracolumbar region M4826 Kissing spine, lumbar region M4827 Kissing spine, lumbosacral region M4831 Traumatic spondylopathy, occipito-atlanto-axial region M4832 Traumatic spondylopathy, cervical region M4833 Traumatic spondylopathy, cervicothoracic region M4834 Traumatic spondylopathy, thoracic region M4835 Traumatic spondylopathy, thoracolumbar region M4836 Traumatic spondylopathy, lumbar region M4837 Traumatic spondylopathy, lumbosacral region M4838 Traumatic spondylopathy, sacral and sacrococcygeal region M5000 Cervical disc disorder with myelopathy, unsp cervical region M5001 Cervical disc disorder with myelopathy, high cervical region M5002 Cervical disc disorder with myelopathy, mid-cervical region M50020 Cerv disc disord with myelpath, mid-cervical rgn, unsp level M50021 Cervical disc disorder at C4-C5 level with myelopathy M50022 Cervical disc disorder at C5-C6 level with myelopathy M50023 Cervical disc disorder at C6-C7 level with myelopathy M5003 Cervical disc disorder w myelopathy, cervicothoracic region M5010 Cervical disc disorder w radiculopathy, unsp cervical region M5011 Cerv disc disorder with radiculopathy, high cervical region M5012 Cervical disc disorder w radiculopathy, mid-cervical region M50120 Mid-cervical disc disorder, unspecified level M50121 Cervical disc disorder at C4-C5 level with radiculopathy M50122 Cervical disc disorder at C5-C6 level with radiculopathy M50123 Cervical disc disorder at C6-C7 level with radiculopathy M5013 Cervical disc disorder w radiculopathy, cervicothor region M5021 Other cervical disc displacement, high cervical region M5022 Other cervical disc displacement, mid-cervical region M50220 Other cerv disc displacmnt, mid-cervical region, unsp level M50221 Other cervical disc displacement at C4-C5 level M50222 Other cervical disc displacement at C5-C6 level M50223 Other cervical disc displacement at C6-C7 level M5023 Other cervical disc displacement, cervicothoracic region M5031 Other cervical disc degeneration, high cervical region M5032 Other cervical disc degeneration, mid-cervical region M50320 Other cerv disc degeneration, mid-cervical rgn, unsp level
351 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M50321 Other cervical disc degeneration at C4-C5 level M50322 Other cervical disc degeneration at C5-C6 level M50323 Other cervical disc degeneration at C6-C7 level M5033 Other cervical disc degeneration, cervicothoracic region M5081 Other cervical disc disorders, high cervical region M5082 Other cervical disc disorders, mid-cervical region M50820 Other cervical disc disord, mid-cervical region, unsp level M50821 Other cervical disc disorders at C4-C5 level M50822 Other cervical disc disorders at C5-C6 level M50823 Other cervical disc disorders at C6-C7 level M5083 Other cervical disc disorders, cervicothoracic region M5104 Intervertebral disc disorders w myelopathy, thoracic region M5105 Intvrt disc disorders w myelopathy, thoracolumbar region M5106 Intervertebral disc disorders with myelopathy, lumbar region M5114 Intvrt disc disorders w radiculopathy, thoracic region M5115 Intvrt disc disorders w radiculopathy, thoracolumbar region M5116 Intervertebral disc disorders w radiculopathy, lumbar region M5117 Intvrt disc disorders w radiculopathy, lumbosacral region M5124 Other intervertebral disc displacement, thoracic region M5125 Other intervertebral disc displacement, thoracolumbar region M5126 Other intervertebral disc displacement, lumbar region M5127 Other intervertebral disc displacement, lumbosacral region M5134 Other intervertebral disc degeneration, thoracic region M5135 Other intervertebral disc degeneration, thoracolumbar region M5136 Other intervertebral disc degeneration, lumbar region M5137 Other intervertebral disc degeneration, lumbosacral region M5144 Schmorl's nodes, thoracic region M5145 Schmorl's nodes, thoracolumbar region M5146 Schmorl's nodes, lumbar region M5147 Schmorl's nodes, lumbosacral region M5184 Other intervertebral disc disorders, thoracic region M5185 Other intervertebral disc disorders, thoracolumbar region M5186 Other intervertebral disc disorders, lumbar region M5187 Other intervertebral disc disorders, lumbosacral region M519 Unsp thoracic, thoracolum and lumbosacr intvrt disc disorder M530 Cervicocranial syndrome M531 Cervicobrachial syndrome
352 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M532X7 Spinal instabilities, lumbosacral region M532X8 Spinal instabilities, sacral and sacrococcygeal region M5384 Other specified dorsopathies, thoracic region M5385 Other specified dorsopathies, thoracolumbar region M5386 Other specified dorsopathies, lumbar region M5387 Other specified dorsopathies, lumbosacral region M5388 Oth dorsopathies, sacral and sacrococcygeal region M5403 Panniculitis aff regions of neck/bk, cervicothor region M5404 Panniculitis affecting regions of neck/bk, thoracic region M5405 Panniculitis affecting regions of neck/bk, thoracolum region M5406 Panniculitis affecting regions of neck/bk, lumbar region M5407 Panniculitis affecting regions of neck/bk, lumbosacr region M5408 Panniculitis aff regions of neck/bk, sacr/sacrocygl region M5409 Panniculitis aff regions, neck/bk, multiple sites in spine M5411 Radiculopathy, occipito-atlanto-axial region M5412 Radiculopathy, cervical region M5413 Radiculopathy, cervicothoracic region M5414 Radiculopathy, thoracic region M5415 Radiculopathy, thoracolumbar region M5416 Radiculopathy, lumbar region M5417 Radiculopathy, lumbosacral region M5418 Radiculopathy, sacral and sacrococcygeal region M542 Cervicalgia M5431 Sciatica, right side M5432 Sciatica, left side M5441 Lumbago with sciatica, right side M5442 Lumbago with sciatica, left side M545 Low back pain M546 Pain in thoracic spine M62830 Muscle spasm of back M953 Acquired deformity of neck M962 Postradiation kyphosis M965 Postradiation scoliosis M9901 Segmental and somatic dysfunction of cervical region M9902 Segmental and somatic dysfunction of thoracic region M9903 Segmental and somatic dysfunction of lumbar region M9904 Segmental and somatic dysfunction of sacral region
353 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M9910 Subluxation complex (vertebral) of head region M9911 Subluxation complex (vertebral) of cervical region M9912 Subluxation complex (vertebral) of thoracic region M9913 Subluxation complex (vertebral) of lumbar region M9914 Subluxation complex (vertebral) of sacral region M9915 Subluxation complex (vertebral) of pelvic region M9920 Subluxation stenosis of neural canal of head region M9921 Subluxation stenosis of neural canal of cervical region M9922 Subluxation stenosis of neural canal of thoracic region M9923 Subluxation stenosis of neural canal of lumbar region M9924 Subluxation stenosis of neural canal of sacral region M9925 Subluxation stenosis of neural canal of pelvic region M9926 Subluxation stenosis of neural canal of lower extremity M9927 Subluxation stenosis of neural canal of upper extremity M9928 Subluxation stenosis of neural canal of rib cage M9929 Sublux stenosis of neural canal of abdomen and oth regions M9950 Intervertebral disc stenosis of neural canal of head region M9951 Intvrt disc stenosis of neural canal of cervical region M9952 Intvrt disc stenosis of neural canal of thoracic region M9953 Intvrt disc stenosis of neural canal of lumbar region M9954 Intvrt disc stenosis of neural canal of sacral region M9955 Intvrt disc stenosis of neural canal of pelvic region M9956 Intervertebral disc stenosis of neural canal of low extrm M9957 Intervertebral disc stenosis of neural canal of up extrem M9958 Intervertebral disc stenosis of neural canal of rib cage M9959 Intvrt disc stenos of neural canal of abd and oth regions M9960 Osseous and sublux stenosis of intvrt foramin of head region M9961 Osseous and sublux stenosis of intvrt foramin of cerv region M9962 Osseous and sublux stenos of intvrt foramin of thor region M9963 Osseous and sublux stenos of intvrt foramin of lumbar region M9964 Osseous and sublux stenos of intvrt foramin of sacral region M9965 Osseous and sublux stenos of intvrt foramin of pelvic region M9966 Osseous and sublux stenosis of intvrt foramina of low extrm M9967 Osseous and sublux stenosis of intvrt foramina of up extrem M9968 Osseous and sublux stenosis of intvrt foramina of rib cage M9969 Osseous & sublux stenos of intvrt foramin of abd and oth rgn M9970 Conn tiss and disc stenosis of intvrt foramin of head region
354 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code M9971 Conn tiss and disc stenosis of intvrt foramin of cerv region M9972 Conn tiss and disc stenos of intvrt foramin of thor region M9973 Conn tiss and disc stenos of intvrt foramin of lumbar region M9974 Conn tiss and disc stenos of intvrt foramin of sacral region M9975 Conn tiss and disc stenos of intvrt foramin of pelvic region M9976 Conn tiss and disc stenosis of intvrt foramina of low extrm M9977 Conn tiss and disc stenosis of intvrt foramina of up extrem M9978 Conn tiss and disc stenosis of intvrt foramina of rib cage M9979 Conn tiss & disc stenos of intvrt foramin of abd and oth rgn M9981 Other biomechanical lesions of cervical region M9983 Other biomechanical lesions of lumbar region M9984 Other biomechanical lesions of sacral region S130XXA Traumatic rupture of cervical intervertebral disc, init S13100A Subluxation of unspecified cervical vertebrae, init encntr S13101A Dislocation of unspecified cervical vertebrae, init encntr S13110A Subluxation of C0/C1 cervical vertebrae, initial encounter S13111A Dislocation of C0/C1 cervical vertebrae, initial encounter S13120A Subluxation of C1/C2 cervical vertebrae, initial encounter S13121A Dislocation of C1/C2 cervical vertebrae, initial encounter S13130A Subluxation of C2/C3 cervical vertebrae, initial encounter S13131A Dislocation of C2/C3 cervical vertebrae, initial encounter S13140A Subluxation of C3/C4 cervical vertebrae, initial encounter S13141A Dislocation of C3/C4 cervical vertebrae, initial encounter S13150A Subluxation of C4/C5 cervical vertebrae, initial encounter S13151A Dislocation of C4/C5 cervical vertebrae, initial encounter S13160A Subluxation of C5/C6 cervical vertebrae, initial encounter S13161A Dislocation of C5/C6 cervical vertebrae, initial encounter S13170A Subluxation of C6/C7 cervical vertebrae, initial encounter S13171A Dislocation of C6/C7 cervical vertebrae, initial encounter S13180A Subluxation of C7/T1 cervical vertebrae, initial encounter S13181A Dislocation of C7/T1 cervical vertebrae, initial encounter S1320XA Dislocation of unspecified parts of neck, initial encounter S1329XA Dislocation of other parts of neck, initial encounter S134XXA Sprain of ligaments of cervical spine, initial encounter S138XXA Sprain of joints and ligaments of oth prt neck, init encntr S139XXA Sprain of joints and ligaments of unsp parts of neck, init S161XXA Strain of muscle, fascia and tendon at neck level, init
355 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code S230XXA Traumatic rupture of thoracic intervertebral disc, init S23100A Subluxation of unspecified thoracic vertebra, init encntr S23101A Dislocation of unspecified thoracic vertebra, init encntr S23110A Subluxation of T1/T2 thoracic vertebra, initial encounter S23111A Dislocation of T1/T2 thoracic vertebra, initial encounter S23120A Subluxation of T2/T3 thoracic vertebra, initial encounter S23121A Dislocation of T2/T3 thoracic vertebra, initial encounter S23122A Subluxation of T3/T4 thoracic vertebra, initial encounter S23123A Dislocation of T3/T4 thoracic vertebra, initial encounter S23130A Subluxation of T4/T5 thoracic vertebra, initial encounter S23131A Dislocation of T4/T5 thoracic vertebra, initial encounter S23132A Subluxation of T5/T6 thoracic vertebra, initial encounter S23133A Dislocation of T5/T6 thoracic vertebra, initial encounter S23140A Subluxation of T6/T7 thoracic vertebra, initial encounter S23141A Dislocation of T6/T7 thoracic vertebra, initial encounter S23142A Subluxation of T7/T8 thoracic vertebra, initial encounter S23143A Dislocation of T7/T8 thoracic vertebra, initial encounter S23150A Subluxation of T8/T9 thoracic vertebra, initial encounter S23151A Dislocation of T8/T9 thoracic vertebra, initial encounter S23152A Subluxation of T9/T10 thoracic vertebra, initial encounter S23153A Dislocation of T9/T10 thoracic vertebra, initial encounter S23160A Subluxation of T10/T11 thoracic vertebra, initial encounter S23161A Dislocation of T10/T11 thoracic vertebra, initial encounter S23162A Subluxation of T11/T12 thoracic vertebra, initial encounter S23163A Dislocation of T11/T12 thoracic vertebra, initial encounter S23170A Subluxation of T12/L1 thoracic vertebra, initial encounter S23171A Dislocation of T12/L1 thoracic vertebra, initial encounter S233XXA Sprain of ligaments of thoracic spine, initial encounter S330XXA Traumatic rupture of lumbar intervertebral disc, init encntr S33100A Subluxation of unspecified lumbar vertebra, init encntr S33101A Dislocation of unspecified lumbar vertebra, init encntr S33110A Subluxation of L1/L2 lumbar vertebra, initial encounter S33111A Dislocation of L1/L2 lumbar vertebra, initial encounter S33120A Subluxation of L2/L3 lumbar vertebra, initial encounter S33121A Dislocation of L2/L3 lumbar vertebra, initial encounter S33130A Subluxation of L3/L4 lumbar vertebra, initial encounter S33131A Dislocation of L3/L4 lumbar vertebra, initial encounter
356 Table 20 ICD-10 Diagnosis Codes Related to the Spine for Chiropractic Coverage
The following list should be used when billing Chiropractic services for ages 21-999. Procedure Procedure Description Code S33140A Subluxation of L4/L5 lumbar vertebra, initial encounter S33141A Dislocation of L4/L5 lumbar vertebra, initial encounter S332XXA Dislocation of sacroiliac and sacrococcygeal joint, init S3339XA Dislocation of oth prt lumbar spine and pelvis, init encntr S335XXA Sprain of ligaments of lumbar spine, initial encounter S336XXA Sprain of sacroiliac joint, initial encounter S338XXA Sprain of oth parts of lumbar spine and pelvis, init encntr S339XXA Sprain of unsp parts of lumbar spine and pelvis, init encntr
Table Listing, Previous Table 20, End of Document
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